disadvantages of home visit

Home Visit Network

Pros & Cons of Home Visits - Patients and Clinicians

Striking a Balance: The Mutual Benefits and Challenges of In-Home Health Care in Australia's Allied Health Sector

In allied health, the challenge is to meet the demand for services. Australia’s 195,000 allied health professionals deliver an estimated 200 million health services annually. The allied health workforce is increasing rapidly as demand grows across the aged care and disability sectors.

To cater for an aging population many allied health professionals prefer to provide direct health care services to patients in their own homes, providing high quality services which are amongst the best in the world.

• No more making appointments
• No more waiting rooms
• No more driving loved ones across town

As with every choice in life, there are pros and cons for both the patient and their clinician. Fortunately, the pros far outweigh any previous challenges faced by either party. Today’s allied health providers can visit the homes of their patients and provide high-quality care when it is needed.

Why Home Health Care is Necessary

When recovering from an injury or simply dealing with an aging body, keeping patients comfortable and feeling as capable as possible is essential. For many, mobility restrictions drive patients in the direction of home-based care, providing comfort and safety in familiar surroundings. Allied Health professionals are trained and capable of helping patients and their loved ones learn more about the types of exercises and treatments they need. They also help with making adjustments to accommodate changes in mobility and health. Working with an allied health professional in the home helps patients become more confident in their day to day activities. It also helps focus on the fact that what they are doing is based on a plan that was created specifically for them – not for patients in general.

PROS of PATIENTS utilising home health care

1. No waiting times. On any given day, therapists may not be sure what services they’ll be performing, leading to extended waiting times for their next patient. A home visit eliminates the inconvenience of not only travel time, but unexpected waiting room blow outs. 2. Less Exposure to outside elements. Reducing the risk of coming into contact with seasonal diseases or Covid- 19. No need to sit in a waiting room social distancing, not knowing if others have been exposed to, or infected with Covid-19, and are not yet symptomatic. 3. Family members are involved in care. When an allied health professional visits and treats a patient in their home, others can be present. Instead of being surrounded by clinicians in a medical facility, patients know that someone they explicitly trust can help to monitor the care being received. 4. One on one care is provided. Patients who receive home health care know that the professional they see is focused entirely on them during each session. 5. Staying home is easier. For people with mobility issues, even getting to appointments can be a challenge. 6. In-home health care allows patients to practice immediately. Doing an exercise in a wide-open space is one thing. Being able to utilise actual permanent surroundings is another thing entirely. By holding physical therapy sessions in a patients home, the therapist is able to demonstrate exactly what patients can do in the home for themselves, and how it should be done. 7. Cost effective. Home health care is recognised by most health providers as being more cost effective than traditional inpatient care, when comparing average payments across setting such as skilled nursing facilities, inpatient residential facilities, and long-term care hospitals. 8. Modern Technology. Dedicated websites give you access to all local in home services. Eftpos payments and Medicare rebates are all available via mobile phone apps.

CONS of PATIENTS utilising home health care

1. Increased stress levels. Home is where a person should feel most comfortable. Sometimes having an outside influence enter it can cause people to feel uncomfortable and as if they are losing their independence. To overcome this, it’s important to remind patients that while they do in fact have people coming into their home, this is being done in order to ensure that they can remain at home for as long as possible. 2. The environment won’t be as structured as it would be in a facility. Sometimes home health care takes away the ability for the therapist to utilise all available tools. For example, equipment that won’t fit into a car, requiring a more thoughtful way to structure the sessions to meet needs. 3. A patient’s conditions or needs may not be met with what is available in the home. What works for one individual may not work for another. One common solution is to commence treatment outside of the home and when the condition has improved, re-evaluate and assess if home care has become a viable option.

PROS of CLINICIANS utilising home health care

1. Self-employment opportunities. Work when you want… Part time, full time, weekends, Work around your normal hours of employment and build up your personal patient base. Take time off for the school pick up, school holidays, personal time, even holidays. 2. No down time. Unlike a clinical situation with gaps between appointments or “no shows”, all your patients are at home and therefore flexible when you attend. 3. Small overheads. None of the necessary overheads running a clinic… No rent, no electricity, no staff, no office furniture. 4. Virtual office. Book appointments, access and write medical notes, online accounting, submit Medicare/DVA claims, promote your services on social media, all without having to pay staff. 5. Mobile phone banking. Instant payment through Tap and Go using phone apps, send and receive faxes, and perhaps, best of all… Google maps!

CONS of CLINICIAN’S utilising home health care

1. Longer visits. Compared to the clinical environment, care for patients at home requires longer visits. Home- based care practitioners see, on average, just five to seven patients a day. 2. Clinical safety. There are specific risks to clinician’s safety in the home setting. These include: environmental hazards such as infection control, sanitation, and physical layout. Difficulty of balancing patient autonomy and risk, and the different needs of patients receiving home based care. Clinicians are understandably disinclined to visit homes in areas with high rates of crime. Some mobile apps provide access to immediate emergency response through a “panic button” used by home-based care teams. 3. Lack of supporting infrastructure. There should be clear inclusion and exclusion criteria to assess the suitability of a home-based solution. Medical schools must prepare the next generation of health providers for the inevitable shift from hospital to home by integrating home-based care into required curriculum and training. Some programs are already taking this step. For example, the John Hopkins University School of Medicine in the USA significantly increased residents’ knowledge, skills, and attitudes relevant to home-base care. Such programs can address the shortage of allied health carers trained in home-based care and fill the gaps in medical education about caring for frail and vulnerable patients. Staying at Home or Home Alone?

Many seniors prefer to remain in their own home for as long as possible, They don’t see themselves as needing support or assistance, even if they do struggle more than they used to. Whether your loved one is at home by circumstance or choice, you worry about their health and safety. Even the most independent seniors may have a bit of trouble getting around as the body slows down. The fact remains: Most older people could use a helping hand. If you have a loved one you’re caring for or concerned about, the Home Visit Network’s directory of in-home services is a great solution.

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5 Obstacles to Home-Based Health Care, and How to Overcome Them

by Pooja Chandrashekar , Sashi Moodley and Sachin H. Jain

Summary .   

One of the most promising opportunities to improve care and lower costs is the move of care delivery to the home. An increasing number of new and established organizations are launching and scaling models to move primary, acute, and palliative care to the home. For frail and vulnerable patients, home-based care can forestall the need for more expensive care in hospitals and other institutional settings. As an example, early results from Independence at Home, a five-year Medicare demonstration to test the effectiveness of home-based primary care, showed that all participating programs reduced emergency department visits, hospitalizations, and 30-day readmissions for homebound patients, saving an average of $2,700 per beneficiary per year and increasing patient and caregiver satisfaction. There are tremendous opportunities to improve care through these home-based care models, but there are significant risks and challenges to their broader adoption.

One of the most promising opportunities to improve care and lower costs is the move of care delivery to the home. An increasing number of new and established organizations are launching and scaling models to move primary, acute, and palliative care to the home. For frail and vulnerable patients, home-based care can forestall the need for more expensive care in hospitals and other institutional settings. As an example, early results from Independence at Home , a five-year Medicare demonstration to test the effectiveness of home-based primary care, showed that all participating programs reduced emergency department visits, hospitalizations, and 30-day readmissions for homebound patients, saving an average of $2,700 per beneficiary per year and increasing patient and caregiver satisfaction.

Partner Center

Revisiting Home Visiting: Summary of a Workshop (1999)

Chapter: challenges faced by home visiting programs, challenges faced by home visiting programs.

The workshop participants identified several critical challenges that face virtually all home visiting programs. They include family engagement, staffing, cultural and linguistic diversity, and conditions, such as maternal depression, that are experienced by many of the participating families.

Family Engagement

The engagement of families in home visitation programs includes the combined challenges of getting families to enroll, keeping them in the program, and sustaining their interest and commitment during and between visits. Parental engagement is essential to the effectiveness of programs and to the validity of research efforts. For example, ongoing reanalyses conducted by Margaret Burchinal, of the University of North Carolina at Chapel Hill, Jeanne Brooks-Gunn, of Columbia University’s Teachers College, and Michael Lopez, of the Administration on Children, Youth, and Families, of data from the Comprehensive Child Development Program revealed that families at two sites that successfully provided more home visits per participating family showed significant effects on child cognitive outcomes compared with control group families; families at sites that offered less home visiting were significantly below the control group in child outcomes. As noted in the Spring/Summer 1999 issue of The Future of Children, programs “rely to some extent upon changes in parental behavior to generate changes in children’s health and development. If parent involvement flags between visits, then changes in children’s behavior will be much harder to achieve” (Gomby et al., 1999). This general conclusion was repeated throughout the workshop by both practitioners and researchers.

Mildred Winter, of the Parents as Teachers National Center, Inc., cited one of the main barriers to the success of home visiting programs to be the lack of motivation of parents to commit to the program. Many others acknowledged that home visiting is a relatively invasive procedure that entails a huge commitment of time and energy on behalf of parents, primarily mothers. It is therefore not surprising that The Future of Children review indicated that families typically received only half the number of visits prescribed. “The consistency with which this occurs across the models suggests that this is a real phenomenon in implementation of home visiting programs” (Gomby et al., 1999). Even when motivated and eager to participate, as noted by workshop participants, families miss visits because of difficulties associated with rescheduling, given busy families and home visitors with large caseloads.

Workshop participants were in agreement that one of the keys to keeping the family engaged throughout the duration of the program is a good relationship between the home visitor and the family. In the Infant Health and Development Program, home visitors’ ratings of parental engagement in the visits were highly predictive of program effects. As noted by Janet Dean, of the Community Infant Program in Boulder, Colorado, “Home visitors need to create a good relationship -- a safe context -- with the family before they can help the family. ” Although some programs target children directly, most home visiting programs are premised on the belief that parents are effective mediators of change in their children, and therefore target the parents directly. Despite the positive findings of some evaluations (such as the reanalysis of data from the Comprehensive Child Development Program), Brooks-Gunn noted that, in general, there is

not much evidence to back up the belief in this premise, nor is there a good appreciation for the difficulty of creating sufficient behavioral change in parents to actually improve child functioning. Workshop participants were in agreement that what is needed is better measurement and understanding of the relationship between the home visitor and the mother.

Attrition is endemic to home visitation. Many families not only miss visits, but also leave the program altogether before it is scheduled to end. For example, of the programs reviewed in Spring/Summer 1999 issue of The Future of Children, attrition rates ranged from 20 to 67 percent. Anne Duggan, of Johns Hopkins University’s School of Medicine, reported that the program ’s approach to retention can affect attrition rates. The three Hawaii Healthy Start programs that she studied had highly variable attrition rates (from 38 to 64 percent over one year). The program with the lowest attrition rate actively and repeatedly tracked down families that tried to drop out, whereas the program with the highest attrition rate assumed that if the parent did not want to be involved, it was not the program’s responsibility to push her.

What can programs do to increase engagement? Olds surmised that enrolling mothers into the Nurse Home Visiting Programs while they were still pregnant with their first child and therefore highly motivated to learn about effective parenting strategies improved retention rates. Another strategy, which was mentioned by many at the workshop, is to make parents part of the program planning process. This may help parents “buy into” the program from the beginning, in addition to ensuring that the program really addresses the needs of the families it intends to serve. Parents need to believe that the home visiting services will help them accomplish goals that they have set for themselves and that warrant an extensive commitment. Answering the question of how to improve engagement is still a big challenge and an issue that needs much more systematic examination as part of implementation studies.

Virtually every speaker at the workshop commented that the home visitor ’s role is critical. As noted by Melmed, “Any service program is only as good as the people who staff it.” In the case of home visiting, the demands on the staff are diverse and often stressful. They must have “the personal skills to establish rapport with families, the organizational skills to deliver the home visiting curriculum while still responding to family crises that may arise, the problem-solving skills to be able to address issues that families present in the moment when they are presented, and the cognitive skills to do the paperwork that is required” (Gomby et al., 1999). Workshop participants identified challenges associated with finding appropriate staff, retaining staff, offering the necessary training and supervision, and matching staff to families with differing needs and predilections, some of which are culturally based and others that are not.

Program designers differ in their views about appropriate staff. Some programs, such as the Nurse Home Visitation Program, rely heavily on professionals (people with degrees in fields relevant to home visiting, such as nursing), but the majority of home visiting programs use paraprofessionals who often come from the community being served and typically have less formal education or training than professional staff beyond that provided by the program. There is an active debate in home visiting over which type of staff is most effective at delivering the curriculum and achieving results. The Nurse Home Visitation Program is based on the premise

that nurses are more effective home visitors than paraprofessionals. An evaluation of the Nurse Home Visitation Program in Denver, Colorado, found that families visited by nurses have a lower rate of attrition and complete more visits than families visited by paraprofessionals, even though the paraprofessionals worked just as hard as the nurses to retain families. Olds speculated that the families conferred greater authority upon the nurses and that the nurses were better equipped to respond to the mothers’ needs and feelings of vulnerability. As a result, the mothers may have complied more willingly with the nurses ’ guidance.

Others see paraprofessionals as better than professionals at creating the essential relationship with the family, because there is less social distance between paraprofessionals and the families they serve. Pilar Baca, of the Kempe Prevention Research Center for Family and Child Health and a trainer of staff for the Nurse Home Visitation Program, noted that the choice of staff is really a question of “for whom, for what?” She argued for the development of “robust paraprofessional models” as an alternative to assuming that professionals will be the preferred or even feasible option for all circumstances.

Regardless of the prior background of the visitors, they invariably face extremely complex issues when working with families and require appropriate preparation, ongoing information, and constant feedback to perform their jobs well. Many at the workshop commented on the need for more extensive and higher-level staff training, both before the home visitor begins working with families as well as during the course of their employment. Two aspects of training were mentioned often at the workshop. The first pertained to ensuring that the home visitors are well versed and accepting of the desired objectives and the philosophy of the particular home visiting program that they are responsible for implementing. The second had to do with the relatively poor ability of some home visitors to recognize conditions such as maternal depression, substance abuse, and domestic violence that interfere with program implementation, family engagement, and effectiveness.

Staff turnover is a significant problem for many programs. For example, the Nurse Home Visitation Program in Memphis had a 50 percent turnover rate in nurses due to a nursing shortage in the community. Other programs relying more on paraprofessionals reported even higher turnover rates. The Nurse Home Visitation Program in Denver, for example, had no turnover among the nurses who were providing home visits, but substantial turnover among the paraprofessionals. The specific impact of turnover on the effectiveness of programs is unknown, but it is likely to present a real problem since the quality of the home visitor/mother relationship is so predictive of program efficacy.

In this area, home visiting may be able to learn from the experiences of the child care field, since both have similar levels of turnover. In the child care field, turnover has been linked to the low wages earned by child care workers as well as to the quality of care received by children and families. Home visiting positions are also typically low-paying and stressful, and it makes sense that many staff will leave if they find a better-paying opportunity. Other keys to staff retention discussed at the workshop include good supervision and good morale. Providing home-based services can be isolating for the home visitor and, as such, requires a higher, more intense level of supervision. At the same time, because supervisors do not typically accompany staff on home visits and therefore do not observe home visitors performing the intervention, it

can be difficult for them to help the home visitor reflect on and learn from their experiences. Despite these difficulties, home visitors need supervision that goes beyond “did you do your job or not” to include elements of social and emotional support, teamwork, and recognition of staff effort. Terry Carrilio, of the Policy Institute at the San Diego State University School of Social Work, aptly observed that the “process needs to reflect what you are trying to do. If a program does not treat its staffwell, how can we expect the staff to deliver a supportive service? ”

Cultural and Linguistic Diversity

Cultural and linguistic considerations are also involved in the decision of who can best deliver home visiting services, but they encompass many other complex issues as well. Home visiting programs deal with fundamental beliefs about how a parent interacts with a child. These beliefs, which are heavily imbued with cultural meaning, provide the foundation for the design and implementation of any program. As noted by Baca, for example, it is likely to be more difficult for a home visitor from a culture different from that of the family to distinguish between practices and beliefs that are culturally different and those that are culturally dysfunctional. This applies as well to evaluators. Linda Espinosa, of the Department of Curriculum and Instruction at the University of Missouri, cautioned that there are possible ripple effects when “we start changing highly personal, highly culturally embedded ways of interacting and socializing children within the family unit. We hope the effects are positive, but we cannot ignore the possibility that they could be negative.” In this context, Espinosa specifically mentioned the potential for programs to upset “the fragile balance of power within the family.”

Decisions about using bicultural and bilingual home visitors are often determined by forces beyond the control of the program. For example, the Family Focus for School Success program in Redwood City, California, chose to hire paraprofessionals because, as Espinosa described, “there were no certificated or B.A.-level people who were bilingual and bicultural and who were floating around in the community waiting to be hired.” Program developers made the decision that having bilingual and bicultural staff was more important than having professional staff. This issue creates certain challenges when programs are expanded since it may not be possible to find enough people willing to be home visitors with the necessary qualifications. The basic question, as for all interventions, is: “Do our goals and outcomes align with the hopes, dreams, and aspirations of the families we serve?”

Domestic Violence, Maternal Depression, and Substance Abuse

Three conditions that can significantly impede the capacity of a home visiting program to benefit families were identified and discussed at the workshop: domestic violence, maternal depression, and substance abuse. Home visiting programs generally set goals that are preventive in nature: to prevent child abuse and neglect, to improve the nutrition and health practices of the mother, to reduce the number of babies born with low birthweight, and to promote school readiness and prevent school failure. However, the families that are targeted by home visiting programs often experience other problems, such as maternal depression, substance abuse, and domestic violence, that need to be addressed before the prevention goals of the program can be achieved.

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Knock Knock, Teacher's Here: The Power Of Home Visits

Blake Farmer

Ninety percent of students at Hobgood Elementary in Murfreesboro, Tenn., come from low-income households. Most of the school's teachers don't. And that's a challenge, says principal Tammy Garrett.

"If you only know middle-class families, you may not understand at times why they don't have their homework or why they're tired," Garrett says.

When she became principal four years ago, Garrett decided to get her teachers out of their classrooms — and comfort zones — for an afternoon. Once a year, just before school starts, they board a pair of yellow buses and head for the neighborhoods and apartment complexes where Hobgood students live.

En route, the bus driver describes over the intercom how he picks up 50 children at one complex each morning. The teachers pump themselves up with a chant. After all, they're doing something most people don't enjoy: knocking on doors unannounced.

When the caravan arrives at a cluster of apartments, the teachers fan out and start knocking on doors of known Hobgood families. Some encounters don't get beyond awkward pleasantries and handing over fliers about first-of-the-year festivities. Others yield brief but substantive conversations with parents who might be strangers around school.

Jennifer Mathis has one child still at Hobgood and says she appreciates that the school came to her — since she has a hard time getting to school.

"I don't have a car. I can't drive because my back got broken in two places," she tells a trio of teachers standing in her doorway. "I'm a mom. I can't be there with all of them all the time."

Giving Home Visits A Try

There was a time when a teacher showing up on a student's doorstep meant something bad. But increasingly, home visits have become a tool to spark parental involvement. The National Education Association has encouraged more schools to try it out, and there's this national effort .

One district in Massachusetts just added money to pay teachers for the extra work involved. Traditional schools in Washington, D.C., tried out home visits after privately run charter schools used them to successfully engage parents.

In Murfreesboro, principal Garrett sees the brief visits as mutually beneficial. Parents get to meet their kids' teachers. And teachers get a clearer sense of the challenges many of their students struggle with on a daily basis.

"If a kid doesn't have a place to sleep or they have to share the couch with their siblings at night and there are nine kids with one bedroom or two bedrooms, it's important for them to see that — not to be sympathetic," she says. "It's to empower the teachers to change the lives of the kids."

It's serious business. But Danielle Hernandez, a special education teacher, says it's not the somber experience she'd feared. At one apartment complex, a dozen kids are out riding bikes on their last day of summer break.

"I know that these children, they go through a lot in their lives," Hernandez says. "But they get to have so much fun."

Teachers join in on that fun, borrowing kids' bikes for a cross-parking-lot drag race that generates howls from the adults.

Ashlee Barnes, a fourth-grade teacher at Hobgood, says she's a believer, even if home visits have yet to prove themselves as a difference-maker on standardized testing.

"We become more important in their lives than I think we can ever understand," she says. "I think the sooner you can start a relationship, you're going to see results on their performance in the classroom."

'It Makes Me Want To Cry'

The kids seem to genuinely enjoy the visits, even if they are a reminder that summer is over.

"I am so lucky," says fourth-grader Shelleah Stephens as she's introduced to Barnes, her new teacher. "All the teachers I have had have been so nice. It's great to see you."

Barnes hugs Shelleah, who is barefoot on the sidewalk in front of the unit where she lives with her father, Kenny Phillips. He's standing back, smiling as his daughter shows off her budding social skills.

"It just brings you this joy. It makes me want to cry," Phillips says.

Phillips runs a landscaping business and says long days have kept him from being as involved with his daughter's education as he'd like to be. Seeing this interaction has him a little choked up.

"It's just good to see her grow up and have people around her who care," he says. "Sometimes parents aren't there, man. Sometimes we gotta work. Sometimes we're gone a lot of the time. It's good to see [teachers] come out to the neighborhood like that. I know she's in good hands."

Phillips also grew up in Murfreesboro but says no teacher stopped by his house. He hopes to return the favor by making sure Shelleah finishes all her homework this year.

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Karen Miller, RN, is a care transition research nurse who coordinates operations for a PCORI-funded multi-site study, which examines whether patients with acute heart failure who receive patient-centered post-discharge care, including a home visit soon after ED discharge, close outpatient follow-up, and subsequent coaching calls, will avoid subsequent ED revisits and inpatient admissions.

Conducting home visits with patients recently discharged from the hospital or emergency department can be a valuable strategy to improve care transitions for patients. According to Karen Miller, RN, a research nurse who specializes in care transitions, home visits enable providers to get a better understanding of the patient within the broader context of their life, and help foster “an intimacy that you cannot achieve in the hospital—patients often share information during home visits that is not typically shared in the hospital setting.”

Miller is part of a research team studying whether patient-centered post-discharge care, including a home visit soon after discharge, can reduce ED revisits and admissions among patients with acute heart failure. A two-person team conducts a home visit and assesses the patient’s status, level of knowledge, and capability to manage their disease. According to Alan Storrow, Associate Professor of Emergency Medicine and study co-investigator, the study team has learned that visiting patients in their home allows providers to “meet patients where they are” along the healthcare continuum and to tailor the patient’s care plan according to their individual needs, goals, and priorities.

In the home setting, patients are more likely to feel relaxed, comfortable, and have a sense of control, in contrast to ED and hospital environments, which can be intimidating. Miller notes that this sense of control translates to a greater sense of self-efficacy and engagement in their own care, an openness and receptivity to education about how to manage their disease, and a sense of true partnership with the provider. Home visits can also provide valuable support and education to family members and caregivers.

Miller says that delivering care in the home has changed her entire perspective on patient care. She also notes that feedback from patients has been extremely positive, with many patients commenting that participating in the program is “the most powerful experience they have had in health care."

Advice for Others

• Relationship building between patients and staff is key to the success of home visit interventions; begin forming a relationship before going to the patient’s home.
• Home visit interventions and care planning require clinical oversight; however, staff conducting home visits do not need to be clinicians.
• Emphasize a patient-centered approach and tailor the patient’s care plan based on their individual capabilities and goals; be flexible to each patient’s needs and priorities.
• Communicate with the patient’s primary care physician and other clinicians (e.g., cardiologist) at the outset and inform them about the patient’s involvement in the program. Emphasize that the visiting provider is a partner in the patient’s care and that the intervention complements and supports the patient’s primary care.
• Realize that interventions require concentrated support at the start of the education process, which can be reduced over time as patients learn to care for themselves.

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Advantages and disadvantages of home care & residential care.

As parents and loved ones become older, their wellbeing and safety can become major concerns . For all of us, our memories can struggle with age, and that can affect how well we look after ourselves. That can range from forgetting to take daily medicines , to having trouble getting out of bed, to falling in the night. It can be scary and upsetting for a grown up child to see their parent get old and struggle, but it is important to be aware when they need extra help.  If you think that your parent needs some extra everyday assistance, there are many care options available. From home care workers to 24 hour residential care. Here we highlight some of the advantages and disadvantages of home care and residential care, to help you make the right decision for your loved ones.

For older adults that are able to do most of their day to day activities independently , but require additional support with cooking, cleaning, house work or getting out and about, home care can be a great option. Many organisations offer a range of support services, so that you and your parent can decide how much support to organise.

Advantages of using home care:

• Carers visit on a daily basis to assist with everything from bathing to cooking, cleaning, buying groceries and taking your parents to doctor’s appointments.
• Individuals can remain in living in their own home and maintain a degree of independence which can be really important for many.
• For those that prefer home comforts, residential care might be overwhelming so home care offers a great intermediary option.
• Home care ensures that family and friends can come over at any time and are not restricted by visitation hours which can be important in maintaining mental wellbeing and preventing loneliness .
• As the older person remains in their own home, and doesn’t get 24 hours care, often, home care is more affordable than residential care.

Disadvantages of home care:

• Although home care may be cheaper on the surface, the home may need fitting with ramps, railings and chairlifts, which can become costly and difficult to organize.
• Many home care agencies change from week to week and this can be unsettling for older people as well as their families. If home care is opted for, make sure all financial options are discussed and that everyone is happy to proceed.
• Some older people may not trust external support. This can make them feel vulnerable and alone. It is important to talk to older parents about their worries, and also consider whether the carer is right for them .
• For older people who are very social, some may enjoy the social side of sheltered housing or residential care- which is not offered by home care.  

Residential Care

Residential care, strictly speaking, is out of home care for those with no longer able to live alone and who have low additional care needs. However, many people and organizations have come to use the term ‘residential care’ to describe all out of home care, including the most complex and intensive care such as nursing care and specialist care for those living with dementia .

If your parent needs extra support and is no longer able to live alone, then residential care can be the right solution. However, the confusion over what term to use can be just the tip of the iceberg with regards to deciding what type of out of home care to look for, and where to look for it. However, the most important thing is to start the research process, consider what advantages and disadvantages residential care could offer and discuss it with your parent . Here we have listed some of the most important pros and cons consider:

Advantages of residential care:

• Residential care is a safe and secure option for older people who are no longer able to live alone, or who are lonely. Residential care ensures all of the individuals living needs are taken care of and the home will provide a room and full board. This will remove the responsibility and worry about doing house work or making own meals.
• Personal and medical care is available 24/7, which can be really helpful for older adults who are lonely, prone to falling , or who require frequent medications but often forget. Having staff on hand all the time to help out can also reassure older people.
• Many residential care homes allow those who are married to stay together. This can be reassuring for many senior citizens who are afraid of separation.
• Most residential care facilities offer activities and trips. Activity programs provided by care teams can vary depending on location, and size of the home, however activities can include gardening, baking, gentle exercise and music. Some residential home also offer specialist activities such as brain training and complementary therapy.

Disadvantages of residential care:

• Residential care is typically more expensive that in home care due to its all inclusive nature and the fact that staff are available 24/7. This can make it difficult to access for some families.
• Residential care can be a nurturing environment. Organisations such as Oomph Wellness , can make life in the home active and enjoyable, offering engaging activities and help with getting out and about. However, despite the activities on offer, some older people can find it difficult to adapt to living in a care environment, and miss their independence. It is important that you talk to your loved ones about residential care, and ask them about the activities they would like to get involved with, and what worries them, before committing to a residential home.
• Although most homes have all-day visiting hours, the location of residential care can be some distance from the family. This makes it harder to maintain family bonds and regular activities. It is important that you consider distances when choosing which care home is right for your loved one.

After considering all the possible advantages and disadvantages, it’s important to remember that everyone is different, and that no matter how elderly your parent may be, or how much care they may require, it is important to include your parents in the discussion about their care to help them feel more comfortable and confident in the care that they receive.  

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• Research article
• Open access
• Published: 09 January 2013

Effectiveness of home visiting programs on child outcomes: a systematic review

• Shelley Peacock 1 ,
• Stephanie Konrad 2 ,
• Erin Watson 3 ,
• Darren Nickel 4 &
• Nazeem Muhajarine 2 , 5  

BMC Public Health volume  13 , Article number:  17 ( 2013 ) Cite this article

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Metrics details

The effectiveness of paraprofessional home-visitations on improving the circumstances of disadvantaged families is unclear. The purpose of this paper is to systematically review the effectiveness of paraprofessional home-visiting programs on developmental and health outcomes of young children from disadvantaged families.

A comprehensive search of electronic databases (e.g., CINAHL PLUS, Cochrane, EMBASE, MEDLINE) from 1990 through May 2012 was supplemented by reference lists to search for relevant studies. Through the use of reliable tools, studies were assessed in duplicate. English language studies of paraprofessional home-visiting programs assessing specific outcomes for children (0-6 years) from disadvantaged families were eligible for inclusion in the review. Data extraction included the characteristics of the participants, intervention, outcomes and quality of the studies.

Studies that scored 13 or greater out of a total of 15 on the validity tool ( n  = 21) are the focus of this review. All studies are randomized controlled trials and most were conducted in the United States. Significant improvements to the development and health of young children as a result of a home-visiting program are noted for particular groups. These include: (a) prevention of child abuse in some cases, particularly when the intervention is initiated prenatally; (b) developmental benefits in relation to cognition and problem behaviours, and less consistently with language skills; and (c) reduced incidence of low birth weights and health problems in older children, and increased incidence of appropriate weight gain in early childhood. However, overall home-visiting programs are limited in improving the lives of socially high-risk children who live in disadvantaged families.

Conclusions

Home visitation by paraprofessionals is an intervention that holds promise for socially high-risk families with young children. Initiating the intervention prenatally and increasing the number of visits improves development and health outcomes for particular groups of children. Future studies should consider what dose of the intervention is most beneficial and address retention issues.

Peer Review reports

Caring for infants and young children can be challenging for many parents; it can be further complicated when families are poor, lack social support, or have addiction problems [ 1 ]. Home visiting (HV) programs attempt to address the needs of these at-risk families with young children by offering services and support that they might not otherwise access. Home visiting programs have been in existence now for more than 20 years [ 2 ]. The benefit of HV programs is that the service is brought to socially isolated or disadvantaged families in their own homes and as such, may increase their sense of control and comfort, allowing them to get the most benefit from services offered. Also offering the programs in the home environment allows home visitors to provide a more tailored approach to service delivery [ 2 , 3 ].

HV programs, however, have difficulties to overcome in order to deliver services. Target families may not accept enrolment into a program or when they do agree may later elect not to begin the program [ 3 ]. Some possible explanations for this include the facts that home visitors may be viewed as intruding or because families may find it difficult to open their homes to home visitors. Achieving consistency in program delivery can also be difficult; families may not receive the planned number of visits, and visitors may not deliver the content according to the program model [ 3 ]. Despite these challenges, the benefits of HV programs outweigh the limitations. To achieve the aims of HV programs it is important that they be shaped by the community and families they serve and that their outcomes be evaluated routinely as part of program improvement.

There are a number of systematic reviews and meta-analyses that explore the effectiveness of HV programs with disadvantaged families [ 4 – 7 ], many of which focus on the prevention of child maltreatment [ 8 – 10 ]. We were not able to locate a systematic review that focused on the delivery of HV programs by paraprofessionals and the effect this method of service delivery has on children’s developmental and health outcomes, so we decided to conduct one to fill this gap in the literature. This work is important to policy-makers and program planners in that these types of programs may be desirable in regions where the higher costs associated with nurse-led HV interventions mean that they are not a feasible option.

The research question for this systematic review was: What is the effectiveness of paraprofessional HV programs in producing positive developmental and health outcomes in children from birth to six years of age living in socially high-risk families? For the purposes of this review, a paraprofessional is an individual delivering an HV program whose credentials do not include clinical training (e.g., developmental psychologist, etc.) and who is not licensed. Socially high-risk families are those who live in poor economic circumstances, receive government assistance or who have inadequate income to meet the needs of the family. We chose broad outcome measures to make the review wide-ranging. These definitions are reflective of the types of programs, families, and research being done with HV programs across North America and elsewhere.

Literature search strategies

An experienced health sciences librarian searched the CINAHL PLUS, Cochrane Library, ProQuest Dissertations and Theses, EMBASE, MEDLINE, PSYCINFO and Sociological Abstracts databases. Weekly alerts from all databases except Cochrane Library were set up to allow inclusion of newly published articles. Where possible, results were limited to the English language with a publication date of 1990 or later (up to May 2012).

Assessment of studies using relevance and validity tools

The tools utilized for assessing the relevance and quality of the studies were based on previously developed tools [ 11 , 12 ]. Article titles and abstracts, when available, were screened by one reviewer to determine whether they might meet eligibility criteria: 1) publication date on or after 1990; 2) written in English; 3) involving an evaluation of an HV program delivered by paraprofessionals; 4) study population of mothers and/or children (0-6) from socially high-risk families; 5) including one of the following outcomes: birth, perinatal, developmental, health and/or risk for occurrences of child abuse/neglect; and 6) incorporation of a control group, pretest/post-test design or quasi-experimental design. A principal reviewer assessed all the papers, and one of two secondary reviewers independently evaluated their relevance, with a third to adjudicate if needed. When necessary, we contacted researchers to clarify components of their research.

Relevant articles were then evaluated to determine the research quality using a validity tool with five items with scores ranging from 0-3, for a total maximum quality score of 15. The tool assessed studies based on how well they addressed potential biases, through assessment of the: (a) design/allocation to intervention (e.g., random assignment {3}, matched cohort {1}); (b) attrition of complete sample (e.g., <17% {3}, >33% {0}); (c) control of confounders (e.g., controlled through RCT design {3}, no evidence of controlling {1}); (d) measurement tools (e.g., well-described/pre-tested tools and blinded data assessors {3}, lack of pretesting and blinding {1}); and (e) type and appropriateness of statistical analysis (e.g., multivariate analysis {3}, descriptive analysis {1}). Two reviewers independently assessed the quality and discussed articles to reach consensus when discrepancies occurred.

Data extraction

We performed data extraction on high-quality studies (i.e., those scoring 13 or greater out of a possible 15), using these categories: (a) study design; (b) purpose or problem; (c) sample details; (d) intervention frequency, duration and provider; (e) instrument(s)/measures utilized; and (f) results and implications of the study. This process was done independently by three reviewers, consulting with each other when necessary.

Data synthesis

We used descriptive synthesis to summarize the characteristics of the participants, intervention, outcomes, and quality of the included studies, based on data extracted. Due to the diversity of the outcomes included in the studies, varying types of statistical analysis conducted, and measures of associations reported, calculation of overall summary estimates (i.e., meta-analysis) was not possible. An alpha level of 0.05 was considered statistically significant for the purposes of this review.

Results and discussion

Literature search.

By using broad search criteria (in order to locate as many potential articles as possible) we identified 2939 records through database searches, which were reduced to 2088 records after duplicates were removed. We found an additional 18 articles by searching the reference lists of all potentially relevant studies. Email alerts resulted in a review of an additional 145 articles, resulting in a total of 2233 articles reviewed. Please see Table  1 that contains a sample of the initial search strategy employed.

Relevance and validity tool assessment

Of the 2233 studies, 809 were excluded by title alone, with an additional 1265 studies excluded following review of their abstracts. A second reviewer randomly selected 10 articles and independently performed the same screening process, reaching the same decisions on exclusion in all 10 cases. Screening and assessing abstracts of studies for relevance to the review yielded 159 potentially relevant articles. One study was no longer accessible, and therefore 158 were assessed with the relevance tool, yielding 71 relevant studies. Inter-rater reliability (kappa) ranged from 0.739 to 0.861 for the reviewing dyads. We applied the validity tool to these 71 studies, with an inter-rater reliability of 0.979, measured via the intra-class correlation. Studies with a score of 13 or higher out of a possible 15 ( n  = 21) were deemed to be of high quality and included in the data extraction (see Figure  1 ).

Summary of selection process.

All studies retained in this review were randomized controlled trials with sample sizes ranging from 52-1297 participants; attrition was less than 24%, and most incorporated multivariate statistical analysis (e.g., analysis of co-variance, multiple regression analysis, or complier average causal effect). Four studies did not pilot test the measures, use well-described tools and/or blind data collectors. Most studies were conducted in the United States ( n  = 15). The relevant outcomes measured were: (a) child abuse and neglect ( n  = 6); (b) developmental delays ( n  = 11); and (c) health assessment ( n  = 10). For each outcome, we report whether the HV intervention had a demonstrable impact. Unless stated otherwise, all control group participants received the usual services offered in their community. Multiple relevant articles arose from the same projects, such as the Healthy Start Program (HSP) and Healthy Families Alaska/New York (see Table  2 for trial characteristics); for sake of clarity these articles are considered individually.

Child abuse and neglect

Child abuse and neglect was often measured using reports recorded with Child Protective Services (CPS) and/or self-reported behaviours of mothers. All of the studies focused on families deemed at-risk for child abuse. Please see Table  3 for a summary of the outcomes of the studies that assessed child abuse and neglect.

Barth [ 14 ] evaluated the Child-Parent Enrichment Project for its impact on preventing perinatal child abuse; pregnant women received, on average, 11 home visits over a 6 month period. In general, self-reported measures did not reveal significant differences in the prevention of child abuse between the intervention and control groups. Self-reported measures and lack of blinding of the assessors were seen as methodological weaknesses of this study.

Bugental and colleagues [ 16 ] assessed the effectiveness of two types of HV interventions compared to a control group. One intervention group received a program based on the Healthy Start model (called the unenhanced group) while the second group received HV with a cognitive change component (the enhanced group). Child abuse was measured on the basis of harsh parenting style using the self-report Conflict Tactics Scale. Bugental and colleagues [ 16 ] found that the enhanced intervention group had less frequent harsh parenting compared to the unenhanced or control groups ( p  = 0.05). As well, the enhanced group mothers were significantly less likely to physically abuse ( p  < 0.05) and least likely to spank/slap their children ( p  < 0.05) compared to the unenhanced or control groups. These findings suggest that enhanced programming (i.e., HV with a cognitive change component) can effectively reduce the frequency and occurrence of harsh parenting among at-risk families. On the other hand, Barth [ 14 ] questions the efficacy of paraprofessional services in preventing abuse and neglect in high-risk families because participants in the Child-Parent Enrichment Program experienced no improvement in prevention of abuse.

Duggan, Berlin, Cassidy, Burrell, and Tandon [ 21 ] undertook an evaluation of Healthy Families Alaska (HFA), assessing reports on child abuse or maltreatment measured by the number of protective service reports filed. Levels of depression/anxiety and maternal attachment were considered moderators of the impact of HV intervention on child welfare. Among non-depressed mothers with moderate to high anxiety, HV was associated with decreased rates of substantiated child maltreatment ( p < 0.05). Among mothers who were not depressed, but had high discomfort with trust/dependence, HV was actually associated with increased rates of substantiated child maltreatment. Thus, benefits of this HV intervention seemed to be limited to certain subsets of at-risk mothers where a number of complex factors were at play. Studies by Duggan, Fuddy and colleagues [ 19 ] and Duggan, McFarlane and colleagues [ 20 ] of the HSP found that there is little impact from paraprofessional services in preventing child abuse and neglect in high-risk families. The researchers surmise that it may be that home visitors are inadequately trained to work with such complex high-risk families, as they were unable to identify family risks and did not provide professional referrals. All the above mentioned studies incorporated large sample sizes, blinded assessors, utilized multiple tools, and ensured study power to detect differences, which can lend credence to the findings.

DuMont and colleagues [ 22 ] assessed Healthy Families New York (HFNY) for the program’s effect on child abuse and neglect, as measured by review of CPS records and self-report of mothers over a two-year period. The researchers indicated that no program effects were noted for the sample as a whole, but that differences were detected between subgroups. By the second year of the intervention, the prevention sub-group (first-time mothers less than 19 years old admitted to the study at less than 30 weeks gestation) was less likely to report engaging in minor physical aggression (over the previous year; p  = 0.02) and harsh parenting behaviours (within the previous week; p  = 0.02) than was the control group. The “psychologically vulnerable subgroup” (women who were less likely to be first-time mothers, were older, and had a higher rate of prior substantiated CPS reports) were less likely to report acts of serious abuse or neglect compared to the control group at year two ( p  < 0.05). The frequency of these acts was also significantly less than among the control group. DuMont and colleagues [ 22 ] suggest that intervening with specific groups of pregnant women can prevent child abuse before it has an opportunity to occur; however, unlike HFNY, assignment of intervention prenatally is not always considered in other large Healthy Families America HV programs.

Developmental delays

A total of 11 studies, one of which was a thesis, measured impacts related to developmental outcomes of children less than six years of age. Specific developmental outcomes included: (a) psychomotor and cognitive development; (b) child behaviour; and (c) language development. Please see Table  4 for the summary of outcomes for the 11 studies that assess developmental outcomes.

Psychomotor and cognitive development

Over half of the studies ( n  = 6) utilized some version of the Bayley Scales of Infant Development (BSID) to assess psychomotor and cognitive development. Black, Dubowitz, Hutcheson, Berenson-Howards, and Starr [ 15 ] undertook a study of an HV program that included weekly visits over a one-year period, conducting analysis on groups of children stratified by age (those < 12 months old and those 12-24 months old). After the 12-month study period, all of the children in the study showed a significant decline in cognitive development overall. However, younger children experienced significantly less decline ( p  = 0.02) compared to age-matched control group children. Differences among the older children were not significant, suggesting that parents of infants may be more receptive to the benefits of an HV intervention compared to parents of toddlers, whose children are undergoing more complex developmental stages. It is important to note that this study may be limited in its generalizability due to the predominantly African American, single mother sample.

The HFAK program was evaluated over a two-year period by Caldera and colleagues [ 17 ] on developmental, behavioural and child health outcomes. The researchers found that 18 months after recruitment, children in the intervention group were significantly more likely to score within the normal range on the BSID (mental development index) than control children ( p  < 0.05). The researchers cautioned that families with a low risk for child abuse may be the only to benefit from this program.

Grantham-McGregor, Powell, Walker and Himes [ 23 ] assessed effects of nutritional supplementation and psychosocial stimulation (conducted by home visitors) over a two year period with stunted 9 – 24 month old children in Jamaica. Only those findings relating to stimulation (alone and in combination) will be discussed here, as supplementation falls outside the scope of this review. Mothers and children assigned to the stimulation group participated in weekly play sessions led by the community health aides; these sessions were designed to promote the children’s development. The measures of development in this study were based on the Griffiths Mental Development Scales, including four subscales: locomotor, hand-eye coordination, hearing and speech, and performance. The researchers found statistically significant improvements in the first 12 months of the study for the stimulated group in regards to developmental quotient and the subscales of locomotor, hand-eye coordination and performance compared to the control group children (all p  < 0.01).

Further, over the whole two years of the study [ 23 ] significant results continued for stimulated children with respect to developmental quotient and all the subscales ( p  < 0.01). Multiple regression analyses of the final developmental quotient scores revealed that the group of children who received both supplementation and stimulation improved significantly more than the stimulated group ( p  < 0.05). The findings suggest that small improvements in mental development can be seen in stunted children who receive a stimulation intervention alone, however, greater benefits are seen when nutritional supplementation is added to the HV intervention. This study does have two limitations: a small sample size, and the use of a developmental tool which was not standardized for use with the local population.

Hamadani, Huda, Khatun, and Grantham-McGregor [ 24 ] conducted a study of developmental outcomes of Bangladeshi children. They measured developmental assessment using the BSID (revised version) before and after 12 months of an HV intervention. Benefits of the intervention on motor development were not significant. They found intervention effects on the mental development index of the BSID ( p  < 0.01), and further, the data were analyzed for children deemed undernourished compared to control group children. Children in the intervention group that were undernourished remained similar to the better-nourished children with respect to mental development on the BSID, but lagged behind on psychomotor development. This study, similar to Grantham-McGregor and colleagues [ 23 ], highlights the interacting or moderating effects of nutrition and its impact on overall child development.

Johnson, Howell and Molloy [ 25 ] assessed psychomotor and cognitive development using games with one-year-old children in Ireland; the intervention group received a home visit once a month. Mothers were asked how often they played either cognitive (e.g., hide and seek) or motor (e.g., playing with a ball) games with their child and this number was recorded with each game played receiving a score. The number of games was totaled with a higher score indicating children were assessed as more developmentally stimulated. Children in the intervention group were significantly more developmentally stimulated with cognitive games compared to the control group ( p  < 0.01); motor development was not significantly different between groups. A note of caution with these findings is the fact that game playing was used as a means to assess developmental outcomes rather than using a standardized tool.

Nair, Schuler, Black, Kettinger and Harrington [ 31 ] compared the psychomotor and cognitive development of 18-month olds with a similar population of substance-abusing mothers. Using the BSID, children in the intervention group who received weekly visits for the first six months of life and then bi-weekly visits up to 24 months had significantly higher scores on the psychomotor developmental index at six months of age ( p  = 0.041) and at 18 months ( p  = 0.01) compared to the control group. The home visits were intended to enhance the mother’s communication with her infant. The researchers suggested there is benefit to using early intervention to improve high-risk children’s psychomotor and mental development.

Child behaviour

Caldera and colleagues [ 17 ] also assessed children for behavioural outcomes, finding that children in the HFAK program scored more favourably on the internalizing scale ( p  < 0.01) and also on the externalizing scale ( p  < 0.01) of the Child Behavior Checklist compared to control group children. The results from this study show that HFAK was able to reduce problem behaviours in young children, to a degree; other factors related to child behaviours (e.g., maternal depression or partner violence) were not influenced by the HFAK program.

Hamadani and colleagues [ 24 ] assessed child behaviour during testing using five 9-point scales. The researchers noted treatment effects for response to the examiner ( p  = 0.01), cooperation with test procedures ( p  = 0.005), emotional tone ( p  = 0.03) and vocalizations ( p  = 0.005); no treatment effect was noted for infant’s activity. This suggests that during testing children in the intervention group benefited in that they were more likely to be willing to engage with the examiner and were more vocal compared to the control group children. It is unclear what the usefulness of these five scales implies on aspects of child behaviour outside of the testing situation within the study.

Language development

Five studies considered findings with respect to language development. Black and colleagues [ 15 ] used the Receptive/Expressive Emergent Language Scale to assess differences in language development between the younger and older groups of children in their study. Both the younger and older children intervention groups experienced significantly less of a decline ( p  = 0.05) in receptive and expressive language compared to their age-matched control groups.

The study by Necoechea [ 32 ] assessed language of three- to four-year-old children using the Peabody Picture Vocabulary Test, Expressive One-word Picture Vocabulary Test-revised, and the Developing Skills Checklist. Testing was done prior to initiation of the Home Instruction for Parents of Preschool Youngsters program, and at the end of the 15-week intervention. Positive treatment effects were noted for the expressive language skills of children ( p  < 0.01) in the intervention group, but no treatment effect was detected for receptive language skills or emergent literacy skills for those same children. The author noted that results should be viewed with caution, as there was substantial variation in the implementation of the intervention, such as number of visits and quality.

Health assessment

Measures assessed included (a) physical growth; (b) number of hospitalizations, illnesses, or injuries; and (c) up-to-date immunizations. Much of the data collected for these outcomes are from medical records. Ten of the included studies assessed health outcomes. Please see Table  5 for a summary of the health outcomes for each study.

Physical growth

Aracena and colleagues [ 13 ] assessed weight among the one year olds in their study and found no statistical difference between the intervention and control groups. The small sample size (n = 45 in each group) may account for part of this finding. Further, there are other factors to consider when assessing height and weight in young children that may not be amenable to a HV intervention (e.g., biological factors).

Black and colleagues [ 15 ] assessed both height and weight for the 12-month duration of their study. They found the HV intervention did not have an impact on children’s growth rates compared to the control group. Hamadani and colleagues [ 24 ] also found that the HV intervention they studied had no impact on improving weight or height for age, or weight for height. Unlike Black and colleagues, Hamadani and colleagues found all children experienced a deterioration in weight for height irrespective of which group they were in (nourished, undernourished, control or intervention). This may, in part, be indicative of the socioeconomic conditions in Bangladesh and the impacts such conditions have on quantities and sources of food.

The Lee and colleagues [ 28 ] study of the HFNY program is one of two studies with significant findings with respect to physical growth; they also included a measurement of low birth weight (i.e., < 2500 g). The earlier in pregnancy the intervention was initiated the lower the odds were of the mother having a low birth weight baby, indicating a dose–response relationship between HV and low birth weight. Compared to control group mothers, HFNY mothers who enrolled earlier than 30 weeks gestation (5.1% versus 9.8%; p  = 0.022), at 24 weeks (5.1% versus 11.3%; p  = 0.008), and at 16 weeks (3.6% versus 14.1%; p  = 0.008) had significantly fewer low birth weight babies. Further analyses supported a dose–response, with greater benefit conveyed to those families enrolling earlier in pregnancy (i.e., thus receiving seven or more visits) (2.7% versus 7.2%; OR = 0.30; p  = 0.079). In the Lee and colleagues study, African American women had the greatest reduction in numbers of low birth weight babies ( p  = 0.022) suggesting that aspects of the environment that African American mothers may find themselves are amenable to change and can result in healthier pregnancies.

Le Roux and colleagues [ 29 ] evaluated an HV program that focused on improving the nutrition of children less than 5 years of age (average age 18 months). Over the one-year-period of the study, 43% of young children in the intervention group showed an acceptable weight-for-age and faster catch up growth compared to 31% in the control group ( p  < 0.01). Appropriate weights at birth and weight gain into toddler years in children are important as this sets the stage for longer-term health benefits [ 29 ]. Findings of this study should be viewed with caution as there was potential for children in most need of supplementation to be steered toward the intervention group despite the intention to randomize participants.

Mclaughlin and colleagues’ [ 30 ] study was designed to assess if birth weight was improved when women were enrolled in an HV program prenatally that included a multi-disciplinary team with paraprofessional home visitors. When comparing the intervention group mothers to control group mothers, the researchers found no significant effect of the intervention in reducing the incidence of low birth weight babies. This finding is in contrast to Lee and colleagues’ findings with the HFNY program.

Number of hospitalizations, illnesses or injuries

Bugental and colleagues [ 16 ] investigated child health as an outcome of their enhanced HV program. As was mentioned previously, they assessed the effectiveness of two types of HV interventions (enhanced and unenhanced) compared to a control group. After completing a health interview with parents, a health score (i.e., frequency of illness, injuries, and feeding problems) was created for each child, where subscales were converted to z- scores and summed. Assessment completed at post-program revealed that the three groups were statistically different ( p  = 0.02), with the enhanced HV group receiving the highest level of benefit in improving child health outcomes (i.e., having the fewest health problems).

In a study conducted in Ireland assessing HV impact on children’s hospitalization outcomes, Johnson and colleagues [ 25 ] found no significant differences between the intervention and control group. They did report however, that children from the intervention group had significantly longer in-hospital stays (14 days) compared to the control group children (7 days; p  < 0.05); the researchers provide no explanation for such a peculiar finding. It would seem that this HV program failed to address aspects of various conditions that can lead to the hospitalization of children.

In a four-year follow-up study, Scheiwe, Hardy and Watt [ 33 ] report findings relevant to this review that are related to improvements in height and weight, general health, and number of dental caries after a seven-month HV intervention to improve feeding practices. Mothers from both the intervention and control groups reported whether their children had experienced any health problems within the last three months; children in the intervention group were less likely to have experienced any health problems compared to the control group children ( p  = 0.01). All other health-related outcomes were statistically not significant between groups. The researchers caution that the significant findings are hard to explain and are likely only chance findings.

Up-to-date immunizations

One study assessed children’s immunization rates. Johnson and colleagues [ 25 ] found that significantly more one-year-old children in the intervention group received three of the primary immunizations (these were not listed in the study) compared to the control group ( p  < 0.01). The results suggest that by empowering parents through an HV program, their children benefited both developmentally and by receiving timely immunizations.

In summary, significant improvements as a result of participating in an HV program are noted for particular parent–child groups. First, some children (e.g., those of psychologically vulnerable women) appear more likely to receive beneficial effects (i.e., protection from abuse and neglect) from an HV intervention, particularly when the intervention is initiated prenatally, than others. Second, HV is associated with developmental improvement and is particularly seen for cognition and problem behaviours, and somewhat less consistently for language skills. Third, in terms of health benefits, improvements are seen in birth weight and appropriate weight gain in early childhood (weight-for-age), fewer health problems, and timely immunizations in children. However, not all evaluated HV programs conclusively show beneficial effects on outcomes in socially high-risk children as evidenced by some studies included in this review.

Implications for practice and future research

On the basis of participating in an HV program, studies reporting no significant benefits are far more prevalent than studies reporting statistically significant benefits. Given the vulnerability of the population and the challenges socially high-risk families encounter, these results are not particularly surprising. The findings from this review tend to point out how difficult it is to change human behaviour, particularly for families that are part of challenging social conditions. While an HV program works to support individual families it can do little to change the context in which socially high-risk families often live.

This review highlights that HV program effectiveness is greatest when: (a) a higher dose of the intervention over a longer period of time is used; (b) mothers are approached prenatally; (c) paraprofessionals are trained adequately to meet the needs of the families they are serving; and (d) the program’s focus is on a particular issue rather than trying to remedy multiple problems. This review addresses the need to assess in detail what is the most beneficial dose of a home visiting intervention in order to produce intended outcomes. Lee and colleagues [ 29 ] demonstrated the association between increased number of visits and reduced odds of having a low birth weight baby. It appears that the earlier an HV program is introduced (ideally prenatally) and the more home visits there are (increased exposure to the intervention), the better the outcomes.

Bugental and colleagues [ 16 ] utilized three groups for comparison: two variants of HV programs and a control group. They demonstrated that by focusing the HV program to improve a particular issue, in their case prevention of child abuse, the outcomes improved. This supports the notion that an intervention is of greater benefit when it is targeted to specific needs of families rather than trying to make a large number of improvements. However, some of the included studies noted that the complexity of the family situation was too multifaceted to be addressed by the HV intervention [ 14 , 17 , 19 , 20 ]. Thus, we suggest that working with multiple risk families poses the question of where to begin ? Perhaps a future consideration might be to target families with fewer challenges in order to determine if they would be more likely to experience significant benefits from HV programming. Also, no one intervention can meet the needs of every family; it may be better to consider an HV intervention as one part of a bigger system of supports and services for socially at-risk families.

Many of the included studies did not indicate the duration of the home visit or how closely home visitors followed the program model [e.g., [ 14 – 18 , 21 , 22 , 24 , 25 ]. This has implications for determining the intensity of the intervention required to generate long-lasting benefits. Perhaps future studies could also assess not only the frequency but the length and quality of visits and how these variables influence intended outcomes of HV programs. More research is required that compares the HV intervention a family receives to the actual program model; in this way it would be possible to discover what does and does not work and for whom.

Given that the majority of studies of home visiting effectiveness have failed to demonstrate benefits, it is important to also consider why that might be the case. Two possible explanations are mentioned here. The first relates to training. Many of the HV programs focused on families with multiple risks (i.e., low income, low education, and substance abuse). These stressful family situations may be overwhelming for a paraprofessional to deal with effectively. It is important to note that all the included studies discussed the paraprofessionals’ training and that they were chosen based on the similarity of life circumstances to the families they were serving. Yet, while similarity of life circumstances may facilitate rapport and trust, it may not supplant the need for home visitors to have specific training to help families in crisis.

Another possible explanation involves duration of the program. For some families in difficult circumstances, their stories involve cyclical crises. Changing such stories may require not only the right resources at the right time, but having access to these over a long period of time; perhaps considerably longer than that which is planned for in standard programs. Both of these possibilities relate to the degree of accommodation of the program to the needs of the family. In order to examine these in research, it might be useful to conduct subgroup analyses, stratifying by level of training of home visitor, complexity of needs of family, and length of time in the program. Analysis of HV program effects for families with non-complex needs may provide greater understanding of the capacity of paraprofessional home visiting to effect change in families. If families with complex needs do not appear to benefit from these programs, then efforts to improve their effectiveness or new programs can be initiated and studied to ensure that these families are well served.

Overall, most studies utilized reliable measurement tools (e.g., some version of the BSID). This type of consistency aids in comparing outcomes of various studies. However, none of the included studies examined the impact of the quality of the relationship between the paraprofessional and the family. The potential benefit of this relationship is either not currently being measured or is not amenable to quantification. It is likely that a mixed-methods approach that includes qualitative data, such as interviews, focus groups with program personnel and families, or observations would provide a deeper understanding of how HV programs provide benefits for families.

All of the included studies used randomized controlled trials, generally believed to be the gold standard in study design. This is ideal in order to address issues of potential bias and to determine if the intervention truly had an impact or not. However, many of the studies did not clearly articulate how randomization was achieved, which may raise concern regarding selection bias. Further, almost half of the studies had one year or less of follow-up and evaluation. It may be beneficial to consider the long-term effects of HV programs later in childhood; only one study in the review was a follow-up study conducted four years after the HV intervention [ 33 ].

Retention of participants is also an issue that requires careful consideration. Almost half of the included studies ( n  = 10 [e.g., [ 14 , 16 , 17 , 19 – 22 , 27 , 30 , 31 ]) had attrition rates of more than 18% of the total sample. Of the studies where attrition was less an issue other factors may have influenced whether a family stayed in the HV program. For example, Hamadani and colleagues [ 24 ] included nutritional supplementation in addition to psychosocial stimulation for one group of children; other studies had weekly or bi-weekly visits as part of the intervention [e.g., [ 15 , 18 , 23 , 24 , 26 , 28 , 32 ]. Perhaps the frequency of visits and the addition of other incentives improve the likelihood of families remaining in an HV program. What challenges a family faces and why they leave a program are important to consider in order to strengthen HV programs to meet the needs of socially high-risk families.

The aim of this systematic review was to assess the state of the literature regarding the effectiveness of paraprofessional HV programs on child outcomes. The effects of HV programs on family members (e.g., mothers, fathers or siblings) of young children would be an interesting avenue of exploration for future reviews. Other focused systematic reviews could include examination of under-developed countries alone (including consideration of non-English studies), less complex family situations (e.g., those with low income only) or follow-up studies that go beyond six years of age of the study children.

Limitations

Overall, this review is limited by the articles retrieved. Other research in this area may have been completed, but was not accessed using standard and systematic literature search and retrieval methods utilized here. None of the researchers contacted provided any other work in progress. The findings of this review must be considered in light of the potential for publication bias, selective reporting within studies and methodological limitations found in the included studies; as well as, in the conduct of the review itself. However, the authors took considerable care to ensure the integrity of the review and to be unbiased in their assessment of the included studies through the use of standardized tools.

This systematic review begins to address a current gap in the research literature by evaluating the effectiveness of paraprofessional HV programs. While this systematic review has shown that HV programs that utilize paraprofessionals often do not have significant effects on disadvantaged families, it does show that young children in these programs show modest improvements in some circumstances. The included studies found that HV intervention programs were associated with decreases in harsh parenting, improved cognition and language development in young children, reductions in low birth weight, improved weight-for-age in young children, and reduction in child health problems. However, findings that were not statistically significant were much more common than significant ones. As discussed, addressing the dose of interventions, approaching women prenatally, focusing programs on improving specific outcomes, making sure paraprofessionals receive adequate training and support, and improving the retention of families all may improve the impacts of HV programs.

Abbreviations

Home visiting

Bayley scales of infant development

Healthy families Alaska

Healthy families New York

Healthy start program.

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SP was involved in reviewing the articles and extracting the data for the study. SP drafted and was responsible for writing the manuscript. SK managed article retrieval, reviewed all articles and was involved in data extraction. SK also assisted in the write up and formatting of the manuscript. EW performed the literature searches. She was also involved in the initial review of all articles to determine the relevance of the articles and provided assistance with editing the manuscript. DN was involved in reviewing the articles and provided assistance with editing the manuscript. NM contributed to the conception and design of the study, provided assistance with drafting the manuscript and is the Principal Investigator on a project on which the study is based. All authors read and approved the final manuscript.

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The advantages of home visits compared to providing care in a clinic setting: Maria Jensberg Leirbakk

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MJ Leirbakk, S Dolvik, JH Magnus, The advantages of home visits compared to providing care in a clinic setting: Maria Jensberg Leirbakk, European Journal of Public Health , Volume 27, Issue suppl_3, November 2017, ckx187.073, https://doi.org/10.1093/eurpub/ckx187.073

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Issue/problem

The majority of early intervention programs directed at families uses home visit as method of program delivery. There seems to be a silent agreement that this is the best strategy and increases the likelihood of promising results and program effects. In Stovner District, Oslo, an early intervention home visiting program was implemented in the existing Maternal and child health care service (MCHS) offering care to a multiethnic population (55%). Public health nurses (PHNs) offered home visits to all first time families from pregnancy until two years of age.

Description of the problem

The same PHNs in the program followed the families at the statutory visits in the MCHS. Key informant interviews with the PHNs and focus group interviews with participating mothers in the program provided insight in how home visits differed from visits at the clinic.

The PHNs described how home visits enabled them to observe the families social environments, interactions and rituals, creating an overall picture that increased their ability to intervene and give tailored guidance and support. In a home setting the PHN felt they could be more personal in relation to the family. She also felt more humble by being a visitor, which created a shift in the power balance and the terms of the meeting, a more equal condition. Her role changed from a practical role at the clinic to a more supportive role in the home. Families felt more comfortable in their home environments and it was easier to talk with the PHN then at the clinic. Enough time was an important aspect. This decreased the level of stress, and the families felt it created a better opportunity to open up and talk about things that was important in their life.

Home visits create a shift in the power balance compared to clinic consultations.

Time is necessary to enhance a trustworthy relationship, which generates an opportunity to tailor guidance and support based on the family’s needs.

It is important to be aware of the changes that occur in home visits compared to clinic consultations.

In preventive interventions at the individual or family level, a trusting relationship is necessary in order to support and help.

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Early Learning

Home visits are effective. here’s why they still make some teachers uneasy., by rachel burstein     feb 19, 2020.

Andy Vinnikov / Shutterstock

This story is part of an EdSurge Research series about the early childhood education workforce.

“Sit near the door. Make sure your car has plenty of gas. Park so you can get out. Don’t wear something that can be a choking hazard like a lanyard.” Macy Jones, the Head Start director for the Alexander County Schools in North Carolina rattles off a list of pointers she gives her staff before they begin their home visits each year. Jones has been concerned about keeping the 37 teachers, assistants and home advocates in her program safe on home visits since she assumed her position seven years ago.

In the past few years, her concerns about staff safety during home visits have increased as she has heard more reports of violent crime in the rural county. “Here we are in 2019, and we don’t know what we’re walking into, or when somebody may show up that came to do harm to somebody in the home. So I’m having conversations now that I never had to have in the ‘80s with folks.” Jones says.

Jones, who attended Head Start herself when she was a child and who has worked at Head Start for over three decades views home visits as critical to the success of both staff and students in the program. But without a full-scale training program and set of comprehensive safety procedures, she isn’t convinced her team should be required to visit the homes of their students. “Head Start really needs to start rethinking the whole home visit requirement,” she says, referencing the federal program that provides high-quality early childhood education to more than one million children from low-income families each year.

For now, Jones lets her staff decide whether to conduct home visits, emphasizing the power of these visits for students. “I tell them they can go somewhere else to meet the parents if they don’t feel safe visiting the family’s home. I say, ‘You don’t have to go...but just remember who doesn’t have an option—those babies we let off the bus every single day. They don’t have an option. So if you can do it, go to that home because those kids’ eyes light up whenever their teachers come see them at their home.’”

Why Conduct Home Visits?

The home visits conducted by Jones’ staff, which occur twice a year, are central to the Head Start model of serving two generations—both children and their families. The visits are mandated by Head Start and complement the work that teachers are doing in the classroom by providing an opportunity for teachers to speak informally with parents or other family members they may not routinely see.

Home visits are also mandated for Head Start’s home-based programs, which typically serve children from birth through age five, including those who are either too young to enroll in preschool, are on a waitlist for a preschool spot or from families who prefer to have their children learn at home. For home-based programs, the weekly home visit of 90 minutes is designed to cultivate parents as teachers. A special role at Head Start, the “parent educator,” visits the homes to introduce parents to the science of early learning and provide specific strategies and activities for advancing children’s brain development. Such intensive home visiting programs also offer a chance for parent educators to identify needed areas of intervention and to identify resources for families.

Head Start isn’t the only preschool program that uses home visits as a way of building community and allowing teachers and programs to help meet students and families where they are—quite literally. Home visits are an increasingly accepted part of early childhood education best practice. In addition to early childhood programs, a handful of K-12 districts are also building home visits into their model. Still, Head Start is the largest early childhood education entity conducting home visits. According to data from the National Head Start Association, Head Start staff members conducted approximately 4.6 million home visits in the 2018-19 school year, including families in both center-based and home-based programs.

There’s good reason for Head Start and other programs to dedicate resources to home visits. Research shows that home visits have a range of benefits, whether they’re designed to supplement preschool attendance or to stimulate learning in the home. Although it looked specifically at elementary school children, a 2015 study from Johns Hopkins University showed that absences declined by about a quarter among students in the Washington, D.C., public schools after a teacher conducted a home visit. The study also found positive correlations between home visits and student achievement. Other studies show that regular home visits from nurses or trained parent educators are correlated with positive effects on children’s neural development, even when those babies and children don’t have child care outside the home.

Home Visits Strengthen Relationships

These outcomes are familiar to Allison Edwards, a lead teacher at a Head Start-affiliated preschool in Tulsa, Okla. Edwards’ preschool is run by CAP Tulsa, a non-profit organization. Edwards says that home visits are important for establishing relationships with her students, especially when they occur early in the school year when children are new to her classroom or to school more generally. “[The kids] want to show us their room. And they want to show us their animals a lot of times, or their favorite toy,” she says.

Equally important, home visits help Edwards better understand the children she teaches so she can develop stronger relationships with them in the classroom. She might meet a grandparent who never comes to school but who is important in a child’s life. A child might show her a favorite toy that Edwards can reference during the school day. She might see bugs and realize that a rash that she was concerned about likely wasn’t a rash at all and that she should make remember to follow-up with family support services.

Edwards agrees with Jones on the value of home visits for children. She laughs as she recounts a recent breakfast conversation among the three year-olds she teaches. Edwards had visited one child at his home the day before and the other preschoolers demanded to know why their teacher hadn’t come to their homes as well. “You have to work through all that with them and say, ‘Well, you know, maybe next time I’ll come to your house. We’ll see,’” says Edwards.

But for all their benefits, home visits can present challenges for early childhood educators. At the very least, Edwards says that it can be “an awkward thing to go visit somebody in their home, especially when we’ve only known them for such a short time.” Many of Edwards’ students come from families who have had negative prior experiences with governmental agencies such as Child Protective Services and who are wary about letting outsiders into their homes. Other parents don’t speak English and Edwards sometimes has to wait on a translator to be available before she is able to schedule those visits.

Safety Concerns

Though there are clear benefits to visiting the homes of students, many early childhood educators have safety concerns. Head Start has some resources available for educators and agencies, but most of these tips , guidance and requirements explore how to build effective relationships and offer sample activities and conversation starters. Those tips that are explicitly designed to address safety concerns are generally simple lists, not training programs or community-building strategies.

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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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Advantages and Disadvantages of Home Visits By Teachers

Looking for advantages and disadvantages of Home Visits By Teachers?

We have collected some solid points that will help you understand the pros and cons of Home Visits By Teachers in detail.

But first, let’s understand the topic:

What is Home Visits By Teachers?

Home visits by teachers are when teachers go to a student’s house to understand their life better. They talk with the family, see the student’s surroundings, and find ways to help them learn better. It’s like a school meeting, but in the student’s own home.

What are the advantages and disadvantages of Home Visits By Teachers

The following are the advantages and disadvantages of Home Visits By Teachers:

Advantages of Home Visits By Teachers

• Builds stronger teacher-student relationships – Home visits by teachers can help establish deeper bonds between teachers and students, fostering mutual respect and understanding.
• Enhances understanding of student’s environment – By visiting a student’s home, teachers can better comprehend the student’s living conditions, which can influence their learning process.
• Improves parent-teacher communication – Regular home visits can significantly improve communication between parents and teachers, leading to a more unified approach towards a child’s education.
• Helps tailor teaching strategies – These visits also offer teachers first-hand insight into a student’s home life, enabling them to adapt their teaching methods to suit individual learning styles.
• Encourages family involvement in education – By involving families in the educational process, home visits can promote a supportive learning environment, boosting a child’s academic performance.

Disadvantages of Home Visits By Teachers

• Invasion of family privacy – Home visits by teachers might infringe on the family’s private space, making them uncomfortable and uneasy.
• Time-consuming for teachers – These visits can be quite time-intensive for teachers, cutting into their personal time and adding to their workload.
• May create safety concerns – Safety can be a concern during these visits, for both teachers and the families involved, due to unforeseen circumstances.
• Could cause student embarrassment – Students might feel embarrassed by their home environment, which could impact their self-esteem and academic performance.
• Potential for cultural misunderstandings – There’s also a risk of cultural misunderstandings, as teachers might unintentionally offend families due to differences in traditions and values.
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