evaluation of home visit

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Learn how "in-home care" can help your loved one and why families across the country have relied on Visiting Angels since 1998 to provide the best senior home care.

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Performing a Home Care Assessment

If you’re thinking about starting home care for an older adult, a home care assessment is an essential first step. At Visiting Angels, a care coordinator will meet with you and your loved one to discuss your care requirements.

You may be overwhelmed by the variety of senior care options available. Anxiety can increase if a loved one has immediate personal care needs . However, an assessment and home care consultation can help ease any trepidations.

Why Do You Need a Home Care Assessment?

A home care assessment is conducted with your loved one’s needs, abilities, and safety in mind, and may include the following:

• A walk-through around the home to look for safety hazards and fall risks
• A discussion about how to optimize the home for maximum safety
• Creating a care plan that outlines the schedule and services provided

A detailed care plan provides a “road map” that outlines when and how a caregiver will perform specific tasks for your loved one.

When is a Home Care Assessment Performed?

A Visiting Angels’ assessment typically occurs after a no-cost, no-obligation home care consultation . During the initial consultation, your loved one and family members will meet with a care coordinator at your loved one’s home.

The initial consultation details the services Visiting Angels provides. Topics for discussion may include:

• Physical care needs, such as bathing, grooming, dressing, meals, and mobility
• Emotional care needs, such as social interaction, activities, hobbies, and conversation
• Schedule, including when your loved one would benefit from having a caregiver in the home
• Assistance with daily activities, such as light housework, groceries, laundry, and meal preparation
• Logistics, such as how to access the home, documentation, and other administrative details
• Preferences, such as favorite music, activities, foods, goals, and expectations

During the initial consultation, if you want to start in-home services as soon as possible, the coordinator may perform a home care assessment during the same home visit.

However, it is common for families to take some time to decide whether home care is the right choice. You can always reach out to Visiting Angels when you are ready and schedule a home care assessment at a later date.

How Can You Prepare for a Home Care Assessment?

Be willing to have an honest discussion about your loved one’s abilities, safety, home environment, and care expectations. Prepare a list of questions important to you and your loved one, and keep it nearby during the assessment.

Visiting Angels’ care coordinators are skilled at discussing delicate personal care concerns in a dignified and respectful way. They can provide a wealth of information and resources to improve your loved one’s safety, quality of life, and well-being.

Contact Visiting Angels

A home care assessment may sound intimidating, but it ensures your loved one’s environment is safe and that everyone is on the same page regarding their care. If you think in-home personal care might be the best choice, contact your nearest Visiting Angels’ home care agency today.

Contact a franchised Visiting Angels office in your area for information on elderly home care services.

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Research on Home Visiting Programs

Keeping up with current research can support your work as a supervisor and your home visitors in their work with families. (See Research on Home Visiting in the Home Visitor’s Online Handbook .)

"The research question about home visiting is not 'does it work?' but 'for whom does it work, under what circumstances?" – Jones Harden et al.[ 1 ]

In 1996, the U.S. Department of Health and Human Services (HHS) launched a large-scale evaluation of the new Early Head Start program. HHS randomly chose families at 17 sites nationally and looked at their social, psychological, developmental, and academic outcomes, compared with those of a matched control group. Families in the control group were able to receive any community services available to them. The evaluation followed families over five time points, according to the child's age: 14 months, 24 months, 36 months, pre-kindergarten, and fifth grade. Below are some of their findings.[ 3 ]

Family Demographics and Family Engagement

"Mental health was related to general and specific engagement, suggesting that home visitation may be effective in addressing underlying mental health issues of parents but also illustrating that the operative component is whether the home visitor is able to successfully engage the mother."  – Raikes et al.[ 4 ]

Family characteristics predicted family engagement in home visiting programs [ 4 ]:

• Teens and single mothers got somewhat fewer services.
• Mobile families had a shorter duration in the program.
• Families of a child with a disability stayed longer and were more engaged.
• Non-English-speaking Hispanic families were more engaged.
• African American families received fewer child-focused experiences.
• White families received more services but were not more engaged.
• Families with more risk factors received fewer child-focused experiences.

Child Outcome Findings

Child-focused experiences are the best indicators of positive school readiness outcomes.

"Certainly, quality of engagement and child focus in the visit are inextricably bound to quantity of visits and these features can only occur within the context of regular home visits."  – Jones Harden et al.[ 1 ]

For Early Head Start children at 36 months, the home-based model had positive effects on:

• Child engagement with the parent in semi-structured play
• The likelihood of an Individualized Education Plan (IEP)
• Standardized cognitive test scores
• Emergency room visits due to accident or injury
• Cognitive and language development
• Parental support for cognitive and language development
• Home environments, which were robustly related to the extent of child-focused activity during the home visit
• Compliance with immunization and well-child visits
• Ongoing contact with the medical home
• Ongoing follow-up and support with children with special needs [ 1 ]

For Early Head Start children in pre-kindergarten, the home-based model had positive effects on:

• Child engagement during parent-child play
• Social behavior problems
• Positive approaches toward learning
• Standardized test scores on problem-solving
• Attending a formal preschool program [ 2 ]

Connecting Research to Practice: Tips for Working with Infants, Toddlers, and Their Families

This series of research-to-practice briefs covers a variety of topics related to early learning and child development. The briefs were developed to support home visitors in their work with children and families. They provide an accessible overview of recent research, as well as resources for families. In addition to home visitors, teachers and family child care providers can use these briefs to learn more about recent research on early childhood development.

Office of Planning, Research & Evaluation (OPRE): Home Visiting

In collaboration with the Health Resources and Services Administration, OPRE manages a number of evaluation activities. Major projects include the Tribal Research Center on Early Childhood and Tribal Home Visiting Evaluation Institute, the Home Visiting Evidence of Effectiveness project, and The Maternal, Infant, and Early Childhood Home Visiting Evaluation.

1 B. Jones Harden, R. Chazan-Cohen, R. Raikes, and C. Vogel. "Early Head Start Home Visitation: The Role of Implementation in Bolstering Program Benefits," Journal of Community Psychology 40, no. 2 (2012): 438–455.

2 T. Adirim and L. Supplee. “Overview of the Federal Home Visiting Program.” Pediatrics: Official Journal of the American Academy of Pediatrics 132 (2013): S59-S64.

3 Early Head Start Research and Evaluation Project (EHSRE), 1996–2010: Project Overview, at http://www.acf.hhs.gov/programs/opre/research/project/early-head-start-research-and-evaluation-project-ehsre-1996-2010  

4 H. Raikes, B. Green, J. Atwater, E. Kisker, J. Constantine, and R. Chazan-Cohen. "Involvement in Early Head Start Home Visiting Services: Demographic Predictors and Relations to Child and Parent Outcomes," Early Childhood Research Quarterly 21 (2006): 2–24.

Resource Type: Article

National Centers: Early Childhood Development, Teaching and Learning

Program Option: Home-Based Option

Audience: Home Visitors

Last Updated: April 25, 2024

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Brief Home Visiting: Improving Outcomes for Children

What is Home Visiting?

Home visiting is a prevention strategy used to support pregnant moms and new parents to promote infant and child health, foster educational development and school readiness, and help prevent child abuse and neglect. Across the country, high-quality home visiting programs offer vital support to parents as they deal with the challenges of raising babies and young children. Participation in these programs is voluntary and families may choose to opt out whenever they want. Home visitors may be trained nurses, social workers or child development specialists. Their visits focus on linking pregnant women with prenatal care, promoting strong parent-child attachment, and coaching parents on learning activities that foster their child’s development and supporting parents’ role as their child’s first and most important teacher. Home visitors also conduct regular screenings to help parents identify possible health and developmental issues.

Legislators can play an important role in establishing effective home visiting policy in their states through legislation that can ensure that the state is investing in evidence-based home visiting models that demonstrate effectiveness, ensure accountability and address quality improvement measures. State legislation can also address home visiting as a critical component in states’ comprehensive early childhood systems.

What Does the Research Say?

Decades of research in neurobiology underscores the importance of children’s early experiences in laying the foundation for their growing brains. The quality of these early experiences shape brain development which impacts future social, cognitive and emotional competence. This research points to the value of parenting during a child’s early years. High-quality home visiting programs can improve outcomes for children and families, particularly those that face added challenges such as teen or single parenthood, maternal depression and lack of social and financial supports.

Rigorous evaluation of high-quality home visiting programs has also shown positive impact on reducing incidences of child abuse and neglect, improvement in birth outcomes such as decreased pre-term births and low-birthweight babies, improved school readiness for children and increased high school graduation rates for mothers participating in the program. Cost-benefit analyses show that high quality home visiting programs offer returns on investment ranging from $1.75 to $5.70 for every dollar spent due to reduced costs of child protection, K-12 special education and grade retention, and criminal justice expenses.

Maternal, Infant and Early Childhood Home Visiting Grant Program

The federal home visiting initiative, the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program, started in 2010 as a provision within the Affordable Care Act, provides states with substantial resources for home visiting. The law appropriated $1.5 billion in funding over the first five years (from FYs 2010-2014) of the program, with continued funding extensions through 2016. In FY 2016, forty-nine states and the District of Columbia, four territories and five non-profit organizations were awarded $344 million. The MIECHV program was reauthorized under the Medicare Access and CHIP Reauthorization Act through September 30, 2017 with appropriations of $400 million for each of the 2016 and 2017 fiscal years. The Bipartisan Budget Act of 2018 ( P.L. 115-123 ) included new MIECHV funding. MIECH was reauthorized for five years at $400 million and includes a new financing model for states. The new model authorizes states to use up to 25% of their grant funds to enter into public-private partnerships called pay-for-success agreements. This financing model requires states to pay only if the private partner delivers improved outcomes. The bill also requires improved state-federal data exchange standards and statewide needs assessments. MIECHV is up for reauthorization, set to expire on Sept. 30, 2022.  

The MIECHV program emphasizes that 75% of the federal funding must go to evidence-based home visiting models, meaning that funding must go to programs that have been verified as having a strong research basis. To date,  19 models  have met this standard. Twenty-five percent of funds can be used to implement and rigorously evaluate models considered to be promising or innovative approaches. These evaluations will add to the research base for effective home visiting programs. In addition, the MIECVH program includes a strong accountability component requiring states to achieve identified benchmarks and outcomes. States must show improvement in the following areas: maternal and newborn health, childhood injury or maltreatment and reduced emergency room visits, school readiness and achievement, crime or domestic violence, and coordination with community resources and support. Programs are being measured and evaluated at the state and federal levels to ensure that the program is being implemented and operated effectively and is achieving desired outcomes.

With the passage of the MIECHV program governors designated state agencies to receive and administer the federal home visiting funds. These designated  state leads provide a useful entry point for legislators who want to engage their state’s home visiting programs.

Advancing State Policy

Evidence-based home visiting can achieve positive outcomes for children and families while creating long-term savings for states.

With the enactment of the MIECHV grant program, state legislatures have played a key role by financing programs and advancing legislation that helps coordinate the variety of state home visiting programs as well as strengthening the quality and accountability of those programs.

During the 2019 and 2021 sessions, Oregon ( SB 526 ) and New Jersey ( SB 690 ), respectively, enacted legislation to implement and maintain a voluntary statewide program to provide universal newborn nurse home visiting services to all families within the state to support healthy child development. strengthen families and provide parenting skills.    

During the 2018 legislative session New Hampshire passed  SB 592  that authorized the use of Temporary Assistance to Needy Families (TANF) funds to expand home visiting and child care services through family resource centers. Requires the development of evidence-based parental assistance programs aimed at reducing child maltreatment and improving parent-child interactions.

In 2016 Rhode Island lawmakers passed the Rhode Island Home Visiting Act ( HB 7034 ) that requires the Department of Health to coordinate the system of early childhood home visiting services; implement a statewide home visiting system that uses evidence-based models proven to improve child and family outcomes; and implement a system to identify and refer families before the child is born or as early after the birth of a child as possible.

In 2013 Texas lawmakers passed the Voluntary Home Visiting Program ( SB 426 ) for pregnant women and families with children under age 6. The bill also established the definitions of and funding for evidence-based and promising programs (75% and 25%, respectively).

Arkansas lawmakers passed  SB 491  (2013) that required the state to implement statewide, voluntary home visiting services to promote prenatal care and healthy births; to use at least 90% of funding toward evidence-based and promising practice models; and to develop protocols for sharing and reporting program data and a uniform contract for providers.

View a list of significant  enacted home visiting legislation from 2008-2021 . You can also visit NCSL’s early care and education database which contains introduced and enacted home visiting legislation for all fifty states and the District of Columbia. State officials face difficult decisions about how to use limited funding to support vulnerable children and families.

Key Questions to Consider

State officials face difficult decisions about how to use limited funding to support vulnerable children and families and how to ensure programs achieve desired results. Evidence-based home visiting programs have the potential to achieve important short- and long-term outcomes.

Several key policy areas are particularly appropriate for legislative consideration:

• Goal-Setting: What are they key outcomes a state seeks to achieve with its home visiting programs? Examples include improving maternal and child health, increasing school readiness and/or reducing child abuse and neglect.
• Evidence-based Home Visiting: Have funded programs demonstrated that they delivered high-quality services and measureable results? Does the state have the capacity to collect data and measure program outcomes? Is the system capable of linking data systems across public health, human services, and education to measure and track short and long-term outcomes?
• Accountability: Do home visiting programs report data on outcomes for families who participate in their programs? Do state and program officials use data to improve the quality and impact of services?
• Effective Governance and Coordination: Do state officials coordinate all their home visiting programs as well as connect them with other early childhood efforts such as preschool, child care, health and mental health?
• Sustainability:  Shifts in federal funding make it likely that states will have to maintain programs with state funding. Does the state have the capacity to maintain the program? Does the state have the information necessary to make difficult funding decisions to make sure limited resources are spent in the most effective way? 

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The Practice of Home Visiting by Community Health Nurses as a Primary Healthcare Intervention in a Low-Income Rural Setting: A Descriptive Cross-Sectional Study in the Adaklu District of the Volta Region, Ghana

Kennedy diema konlan.

1 Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana

2 College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea

Nathaniel Kossi Vivor

Isaac gegefe, imoro a. abdul-rasheed, bertha esinam kornyo, isaac peter kwao, associated data.

The data used to support the findings of this study are included within the article.

Home visit is an integral component of Ghana's PHC delivery system. It is preventive and promotes health practice where health professionals render care to clients in their own environment and provide appropriate healthcare needs and social support services. This study describes the home visit practices in a rural district in the Volta Region of Ghana. Methodology . This descriptive cross-sectional study used 375 households and 11 community health nurses in the Adaklu district. Multistage sampling techniques were used to select 10 communities and study respondents using probability sampling methods. A pretested self-designed questionnaire and an interview guide for household members and community health nurses, respectively, were used for data collection. Quantitative data collected were coded, cleaned, and analysed using Statistical Package for Social Sciences into descriptive statistics, while qualitative data were analysed using the NVivo software. Thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion.

Home visit is a routine responsibility of all CHNs. The factors that influence home visiting were community members' education and attitude, supervision challenges, lack of incentives and lack of basic logistics, uncooperative attitude, community inaccessibility, financial constraint, and limited number of staff. Household members (62.3%) indicated that health workers did not adequately attend to minor ailments as 78% benefited from the service and wished more activities could be added to the home visiting package (24.5%).

There should be tailored training of CHNs on home visits skills so that they could expand the scope of services that can be provided. Also, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants can also be trained to identify and address health problems in the homes.

1. Introduction

Home visit practice is a healthcare service rendered by trained health professionals who visit clients in their own home to assess the home, environment, and family condition in order to provide appropriate healthcare needs and social support services. The home environment is where health is made and can be maintained to enhance or endanger the health of the family because individuals and groups are at risk of exposure to health hazards [ 1 , 2 ]. At home visit, conducted in a familiar environment, the client feels free and relaxed and is able to take part in the activity that the health professional performs [ 1 ]. It is possible to assess the client's situation and give household-specific health education on sanitation, personal hygiene, aged, and child care. The important role the health professional plays during home visits (HV) cannot be overemphasized, and this led Ghana to adopt HV as a cardinal component of its preventive healthcare delivery system. This role is largely conducted by community health nurses (CHN) [ 2 ]. Health education given during HVs is more effective, resulting in behavioural change than those given through other sources such as the mass media [ 3 ].

In the home, the health professionals, mostly CHN monitor the growth, development, and immunization status of children less than 5 years and carry out immunization for defaulters. Care is given to special groups such as the elderly, discharged tuberculosis, and leprosy patients as well as malnourished children [ 1 , 2 ]. It is also possible to carry out contact tracing during HVs [ 2 ]. These services may prevent, delay, or be a substitute for temporary or long-term institutional care [ 4 , 5 ]. HV has potential for bringing health workers into contact with individuals and groups in the community who are at risk for diseases and who make ineffective or little use of preventive health services [ 2 ]. Several factors influence the conduct of HVs. These factors include location of practice, general practitioners age, training status, and the number of older patients on the list and predicts home visiting rate [ 6 ].

The concept of HV has remained in Ghana over the decades, and yet, its very essence is imperative [ 3 ]. In Ghana, home visiting is one of the major activities of CHN. The health visitors, as CHNs were then called, went from house to house, giving education on sanitation and personal hygiene [ 3 ]. These nurses attempt to promote positive health and prevent occurrence of diseases by increasing people's understanding of healthy ways of living and their knowledge of health hazards [ 7 ]. HVs remain fundamental to the successful prevention of deaths associated with women and children under five; yet, there still remain certain gaps in the successful implementation of this innovative intervention in Ghana [ 4 ]. In Sekyere West district in Ashanti Region of Ghana, although nurses had knowledge of home visiting and had a positive opinion of the practice, they could not perform their home visiting tasks or functions up to standard [ 8 ]. Home visiting practice in that district among nurses was found to be very low, even though community members desired more [ 8 ]. The findings indicate that there is a need for HV [ 9 ]. Also identified were several health hazards, such as uncovered refuse containers, open fires, misplaced sharp objects, open defecation, and other unhygienic practices that a proper home visiting regiment can address [ 8 ]. At the service level, lack of publicity about the service, the cost of the service, failure to provide services that meet clients' felt needs, rigid eligibility criteria, inaccessible locations, lack of public transport, limited hours of operation, inflexible appointment systems, lack of affordable child care, poor coordination between services, and not having an outreach capacity were identified as the challenges associated with this kind of service [ 9 – 13 ].

Home visiting is a crucial tool for enhancing family healthcare and the health of every community. Ghana Health Service through home visiting services has supported essential community health actions and address gaps in knowledge and community practices such as reproductive behaviour, nutritional support for pregnant women and young children, recognition of illness, home management of sick children, disease prevention, and care seeking behaviours [ 4 ]. As many interventions are implemented by stakeholders in health to ensure that home visiting practices actually benefit community members, recent studies have not delved into the practices of home visiting in poor rural communities especially in the Volta Region of Ghana. This study assessed the home visiting practices in the Adaklu district (AD) of the Volta Region.

This study assessed the practice of home visiting as a primary healthcare (PHC) intervention in a poor rural district in the Volta Region of Ghana.

2. Methodology

2.1. study design.

This mixed method study employed a descriptive cross-sectional study design as the study involved a one-time interaction with the CHNs and the community members to assess the practice of HVs.

2.2. Study Setting

The AD is one of the districts in the Volta Region of Ghana and has about 40 communities. The district capital and administrative centre is Adaklu Waya. The estimated population of the district was 36391 representing 1.7% of the Volta Region's population before the Oti Region was carved out [ 14 ]. The district is described as a rural district [ 14 ] as no locality has a population above 5000 people. The economically active population (aged 15 and above) represents 67% of the population [ 14 ]. The economically inactive population is in full-time education (55.1%), performed household duties (20.6%), or disabled or too sick to work (4.6%), while the employed population engages in skilled agricultural, forestry, and fishery workers (63.1%), service and sales (12.6%), craft and related trade (14.6%), and 3.4% other professional duties [ 14 ]. The private, informal sector is the largest employer in the district, employing 93.9% [ 14 ]. There are 15 health facilities in the district government health centres [ 4 ], one health centre by Christian Health Association of Ghana, and 10 community health-based planning services (CHPS) of which 5 are functional [ 15 ]. The housing stock is 5629 representing 1.4% of the total number of houses in the Volta Region. The average number of persons per house was 6.5 [ 14 ], and the houses are mostly built with mud bricks [ 15 ]. The most common method of solid waste disposal by households is public dumping in the open space (47.5%). Some households dump solid waste indiscriminately (17.3%), while other households dispose of burning (13.3%) [ 14 ].

2.3. Study Population, Sample, and Sampling Technique

There are about 36391 inhabitants with 6089 households in AD [ 14 ]. This study mainly involved adult members of the household and CHNs from randomly sampled communities in the district. These sampled communities included Abuadi, Anfoe, Ahunda, Dawanu, Goefe, Helekpe, Hlihave, Tsrefe, Waya, and Wumenu. An adult member of the household is a person above the age of 18 years who has the capacity to represent the household. CHN [ 11 ] from the selected communities in the district was recruited. A CHN is a certified health practitioner who combines prevention and promotion health practices, works within the community to improve the overall health of the area, and has a role to play in home visiting.

Estimating for a tolerable error of 5%, with a confidence interval of 95%, and a study population of 6089 households, with a margin of error of 0.05 using Yamane's formula for calculating sample for finite populations, a sample of 375 households were computed. The sample size was increased to 390 to take into consideration the possible effect of nonresponse from participants. Multistage sampling technique was adopted to eventually select study participants. Each community was stratified into four geographical locations: north, south, east, and west with respondents being selected from every second house using a systematic sampling approach. In each household, an adult member of the household responded to the questionnaire.

A whole population sampling method was used to select eleven [ 11 ] CHNs from the specific communities [ 10 ] where the study took place in the district. The CHN that served the 10 selected communities were selected. The numbers selected from each community were Helekpe (18.2%), Waya (18.2%), Anfoe (9.1%), Tsrefe (27.3%) and Wumenu (27.3%). This represented 42.3% of the total CHN community of the district at the time of the study.

2.4. Pretesting

The questionnaire and interview guide were piloted using 30 adult household members and 5 CHNs, respectively, at Klefe CHPS in the Ho municipality. The data collected through the questionnaire were subjected to a reliability test on SPSS (version 22). The pretesting ascertained the respondent's general reaction and particularly, interest in answering the questionnaire. The questionnaire was modified until it produced a Cronbach alpha coefficient of 0.790. It can therefore be concluded that the questionnaire had a high reliability in measuring the objectives of the study. The pretesting helped in identifying ambiguous questions and revising them appropriately. It also helped to structure and estimate the time the respondents used to answer the questionnaires and to respond to the interview.

2.5. Data Collection

Researchers from the University of Health and Allied Sciences School of Nursing and Midwifery were involved in data collection. Five researchers received two days training in data collection, the study tools, and research ethics for social sciences prior to the commencement of data collection. All researchers had a minimum of a bachelor degree in CHN with at least three years' data collection experience.

Respondents were assisted to respond to a questionnaire within their homes. The household questionnaire had four [ 4 ] sections comprising personal details and how HV practice is carried out in the home such as frequency of visit, duration, and activities. Subsequent sections had respondents answer questions on the challenges, benefits, and factors that could promote the HV practice. It took an average of about 15 minutes to complete a single questionnaire.

A semistructured interview guide was used to interview CHNs. This guide was in four sections; the first section was personal details with subsequent sections on practice of home visits, constraints to the practice, the benefits, and promotion factors to HVs. An interview section lasted 20–25 minutes to complete.

2.6. Data Analysis

2.6.1. quantitative data.

Each individual questionnaire was checked for completeness and appropriateness of responses before it was entered into Microsoft Excel, cleaned, and transferred to the Statistical Package for Social Sciences (version 22) for analysis. The data were basically analysed into descriptive statistics of proportions. There were also measures of central tendencies for continuous variables.

2.6.2. Qualitative Data

In data analysis, thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion [ 16 ]. CHNs views were summarised based on the conclusions driven and collated as frequencies and proportions. Guest, Macqueen, and Namey summarised the process of thematic analysis as construing through textual data, identifying data themes, coding the themes, and then interpreting the structure and content of the themes [ 17 ]. In using this scheme, a codebook was first established, discussed, and accepted by the authors. The nodes were then created within NVivo software using the codebook. Line-by-line coding of the various transcripts was performed as either free or tree nodes. Double coding of each transcript was carried out by two of the researchers. Coding comparison query was used to compare the coding, and a kappa coefficient (the measurement of intercoder reliability) was generated to compare the coding that was conducted by the two authors. The matrix coding query was performed to compare the coding against the nodes and attributes using NVivo software that made it possible for the researchers to compare and contrast within-group and between-group responses.

2.7. Ethical Consideration

Ethical clearance was obtained on the 19th September, 2018, from the Research and Scientific Ethics Committee of the Institute of Health Research, University of Health and Allied Sciences (UHAS-REC A.2 [13] 18-19). Permission was sought from the district health authorities, chiefs, and assembly members of each study community. Preliminary to the administration of the questionnaires, an informed consent was obtained as respondents signed/thumb printed a consent form before they were enrolled into the study. Participants could withdraw from the study anytime they wished to do so.

3.1. Household Members' Views regarding Home Visit

The household representatives surveyed (375) had a mean age of 41.24 ± 16.88 years. The majority (26.5%) of household members were aged between 30 and 39 years. Most (75.1%) were females. The majority (97.1%) of people in households were Christians, while 38% was farmers. The majority (69.9%) of household members were married as 47.2% had schooled only up to the JHS level as at the time of this survey as given in Table 1 .

Demographic characteristics of household members.

The majority (73.3%) of adult household members had ever been visited by a health worker for the purpose of conducting HVs as a significant number (26.7%) of household members had never been visited by health workers in the community. Most (52.6%) household members had had their last visit from a health worker during the past month. Within the past three months, some (48.2%) community members were visited only once by a health worker. The majority (93.4%) of community members were usually visited between the time periods of 9am and 2pm as given in Table 2 . The community members contend that home visiting was beneficial to the disease prevention process (65%). The people that need to be visited by CHNs include children under five (25%), malnourished children's homes (14%), children with disabilities (14%), mentally ill people (11%), healthcare service defaulters (22%), people with chronic diseases (9%), and every member of the community (5%).

Practice of home visits in AD (household members).

Most (87.9%) community members were given health education during HVs conducted by the CHN. In describing the nature of health education that is most frequently given by CHNs during HVs, household members indicated fever management (14%), malaria prevention (20%), waste disposal (11%), prevention and management of diarrhoea (22%), nutrition and exclusive breastfeeding (14%), hospital attendance (14%), and prevention of worm infestations (5%). The majority (62.3%) of community members did not receive a minor ailment management during HVs as most (66.5%) of community members received vaccination during HVs by CHNs. Describing the type of minor ailment treatment given during the HV include care of home accidents (13%), management of minor pains (22%), management of fever (45%), and management of diarrhoea (20%). Household members (24.5%) did identify bad timing as a barrier for home visiting, while some (13.1%) did identify the attitude of health workers as a barrier to home visiting. However, most (67.3%) of the household members attributed their dislike for home visiting to the duration of the visit. The majority (95.2%) of household members indicated health workers were friendly. Some household members (78%) indicated they benefited from HVs conducted in their homes. The majority (91.4%) of household members showed that time for home visiting was convenient. Indicating if household members will wish for the conduct of the HV to be a continuous activity of CHNs in their community, the respondents (82%) were affirmative.

3.2. CHNs Views on Home Visit in AD

The mean age of CHNs was 30.44 ± 4.03 years as some (33.3%) were aged 32 years as the modal age. The CHNs (90.9%) were females with the majority (81.8%) being Christians as given in Table 3 .

Demographic characteristics of CHN.

In assessing the home visiting practices of CHNs, the researchers had some thematic areas. These thematic areas that were discussed include but not limited to the concept of HV by CHN, factors that influence the conduct of HVs, ability to visit all homes within CHN catchment area, reasons for conducting or not able to conduct HV, frequency of conducting home visits by CHN, and activities undertaken during HVs. This view that was expressed was simply summarised based on the thematic areas and presented in Table 4 as descriptive statistics related to the CHN conduct of HVs.

Summary of CHNs home visit practice in AD.

3.2.1. Concept of Home Visit by CHN

CHNs have varied descriptions of the concept of HV as it is conducted within the district. The description of HV was basically related to the nature and objective that is associated with the concept. The central concept expressed by participants included a health worker visiting a home in their place of abode or workplace, providing service to the family during this visit, and this service is aimed at preventing disease, promoting health, and maintaining a positive health outcome. These views were summarised when they said

“HVs are a service that we (CHNs) rendered to the client and his family in their own home environment to promote their health and prevent diseases. The central idea is that during the HV, the CHN is able to engage the family in education and services that eventually ensure that diseases are prevented and health is promoted.”

“HV is the art when the CHNs visit community members' homes to provide some basic curative and largely preventive healthcare services to clients within their own homes or workplaces. During this visit, the CHN helps the entire family to live a healthy life and give special attention or care to the vulnerable members of the society.”

“It is the processes when at-risk populations are identified; then, the CHN provides services to this cadre within their own home environment and sometimes workplaces as the case may be. Essentially, the CHN assists the family to adopt positive behaviours that will ensure they live with the vulnerable person in a more comfortable way.”

3.2.2. Factors that Influence the Conduct of Home Visits

The CHNs enumerated a cluster of factors that influence the conduct of HVs within the district. These factors ranged from community members education, attitude, supervision challenges, lack of incentives, and lack of basic logistics to conduct HVs. The uncooperative attitude of community members was identified by CHNs (36.4%) as a barrier to HVs. As they indicate, some community members did not support the continued visit to their homes or did not give them the necessary attention needed for the provision of services.

“Some community members do not understand the importance of HVs in the prevention of disease and for that matter are less receptive to the conduct of HVs. They just do not see the need for the service provider to come to their homes to provide services.”

“The client is the master of his own home; when you get into a home for a HV, the owner should be willing to talk or attend to you. Sometimes, you get into a home and even if you are not offered a seat, or you are just told we are busy, come next time. You know community service is not a paid job, so because the community members do not directly pay for the services we provide, essentially less premium is placed on the activities we conduct.”

“There is some resistance to HVs by some community members. Sometimes, you come to a house and can feel that you are not wanted; meanwhile, the home is part of the home that needs and has to get a HV because of the special needs they have. This is particularly specific in homes that believe that the particular problem is a result of supernatural causes.”

3.2.3. The Ability to Visit All Homes within CHN Catchment Area

The conduct of HVs is a basic responsibility for all CHNs as they remain as an integral part of the PHC delivery system in Ghana. Based on the nature and problems in the community, CHNs strategizes various means that will aid them to provide this essential service efficiently. CHNs (81.8%) are able to visit all homes in the catchment areas during a quarter. Some of the responses included the following:

“We do organise HVs, this is part of our routine schedule. As a community health nurse, to enjoy your work, you will need to organise HVs from time to time.”

“As for the HV, it depends on the strategies a particular CHPS compound is using. Irrespective of the community that one works in, you can always provide full and adequate care and service to the community if you plan well. First, you have to identify the “at need people” then the distance to their homes and put this in your short-term strategic plan for execution.”

“HVs are basic responsibilities of community health nurses, and we ought to execute it. In spite of the challenges, we cannot let those particularly hinder on our ability to conduct our very core mandate.”

Some CHNs were not able to visit all homes in their catchment areas, citing “hard to reach areas” and “Inadequate equipment” as the reasons for not being able to visit all households.

“Sometimes it is the distance to the clients' homes that makes it impossible to visit them. There are some homes if you actually intend to visit them, then you must be willing to spend the whole day doing only that activity.”

“Some clients' problems are such that you will need to have special tools before you visit them. For example, what use will it be to a diabetic client if you visit him/her and you are unable to monitor the blood sugar level or to a hypertension patient, you are not able to check the blood pressure because you do not have the required equipment?”

“To have a successful HV practice, I think the authorities should be willing to provide the basic logistics that will aid us to work. Without this basic logistics, we cannot.”

3.2.4. The Reasons for Conducting or Not Able to Conduct Home Visits

CHNs (72.7%) carried out both routine and special HVs. For those community health nurses who were not able to conduct HVs, several reasons were ascribed. Some of the reasons described included the lack of basic amenities to conduct HVs. The majority (18.2%) of CHNs also did attribute inaccessible geographical areas as a barrier to HV. Also, CHNs (63.6%) identified inadequate logistics and financial constraints as barriers to HV. All of the CHNs report on their activities regarding home visiting to the district health authorities.

“We basically lack the simple logistics that will assist us to conduct HVs. We do not have simple movable equipment like weight scales, thermometers, sphygmomanometers, and stethoscopes.”

“We do not have functionally equipped home visiting bags, so even if we decide to visit the homes, how much help will we be to the client?”

The other reasons included large catchment areas and lack of reliable transportation for the conduct of HVs in the AD.

“The catchment area is quite wide and practically impossible to visit every home. Looking from here to the end of our catchment area is more than 5 kilometers, without a means of transport, one cannot be able to visit all those homes.”

“I remember in those days; community health nurses were given serviceable motor cycles to aid in their movement and especially the conduct of HVs. Today, since our motorbike broke down 5 years ago, it has since not been serviced, yet we are expected to conduct HVs.”

“To conduct home visits, whose money will be used for transportation? The meagre salary I earn? Or the families or beneficiaries of the service have to pay?”

“The number of staff here is woefully inadequate, we are only two people here, how can we do home visiting and who will be left in the facility to conduct the other activities. For this reason, we are not able to conduct HVs.”

CHNs tried to visit the homes at various times depending on the occupation of the significant other of the homes, so that they can provide services in the presence of the significant others. CHNs (63.6%) visit 6–10 homes in a week as 90.9% CHNs conduct HVs in the morning. The reasons given for conducting some HVs in the evenings included the following:

“This place is largely a farming community, most people visit their farms during the mornings, so if you visit the home in the morning, you may not meet the significant others of the vulnerable person to conduct health education.”

“We do HVs because of the clients, so anytime it is possible, we will meet them at home, we conduct the visits at that time. For me, even if the case is that I can only meet the important people regarding the client at night, I visited them at that time. For community health nursing work, it is a 24-hour work and we must be found doing it at all time.”

3.2.5. Frequency of Conducting Home Visits by CHN

Various schedule periods were used based on health facilities for the purpose of HVs. Most (45.5%) conducted HVs three times in a week. CHNs (90.9%) had conducted HVs the week preceding the interview. Indicating that the last time HV was conducted, CHNs conducted a HV at least within the last week:

“HV is a weekly schedule in this facility; for every week, we have a specific person who is assigned to do HV just as all other activities that are conducted in this facility”.

“Yes, last week, we had a number of HVs; we made one routine HV and the other was a scheduled HV from a destitute elderly woman who was accused as a witch by some of her family members.”

Indicating if they sometimes get fatigued for conducting HVs weekly because of the limited number of staff, a community health nurse indicated that,

“I think it is about the plan we have put in place. There are about four people in this facility. We plan our activities that we all conduct HVs. In a month, one may only have one or two HVs, so it is unlikely that you will be fatigued in conducting HVs.”

“Yes, sometimes, it is really tedious, but we cannot let that be a setback. We have a responsibility to execute and we must be doing so to the best of our ability.”

3.2.6. Activities Undertaken during Home Visits

CHNs conducted health education (90.9%), management of minor ailments (54.6%), and vaccination/contact tracing (63.6%) during HVs. Describing if they are able to conduct the management of small ailments and home accidents at home, CHNs were divided in their ability to do this. Those were not able to do so indicated,

“…. And who will pay? Since the introduction of the national health insurance, we are not able to provide management of minor ailments during HVs. In those days, we were supplied with the medicines to use from the district, so we could provide such free services. But with the insurance now in place, we do not get medicine from the district, so whose medicine will you use to conduct such treatment?”

“I think our major goal is on preventive care. We have a lot to do with preventing diseases. Let us leave disease treatment to the clinical people. When we get ailments, we refer them to the next level of care to use their health insurance to access service.”

Identification of cases, defaulter tracing, and health education were identified as benefits and promotion factors of HVs. Identification of cases and defaulter tracing were both mentioned by CHNs as benefits and promotion factors of HVs.

“I think HVs should be continued and encouraged to be able to achieve universal, sustainable PHC coverage for all. Not only do we visit the homes, we also identify vaccination defaulters, tuberculosis treatment defaulters, and prevention of domestic violence against women and children and health education on specific diseases and sometimes we do immunisation.”

“In the home, we have a varied responsibility, treatment of minor ailments, immunization and vaccination, contact tracing, education on prevention of home accidents, etc.” It will be a disservice, therefore, if anyone tries to downplay the importance of HVs in our PHC dispensation.”

“Through HVs, we have provided very essential services that cannot be quantified mathematically, but the community members know the role of the services in their everyday lives. Even the presence of the community health nurse in the home is a factor that promotes girl child education and leads to woman empowerment.”

4. Discussion

This study assessed the home visiting practices in the AD of the Volta Region of Ghana. The concept of home visiting has been enshrined in Ghana's health history and executed by the CHN or public health nurses (PHN). In AD, only CHNs among all the various cadres of health professionals conducted HVs. This was contrary to the practice in the past when both CHN and PHN conducted HVs [ 18 ]. Notwithstanding the limited numbers of CHNs in the district, the majority of households (73.3 %) have a history of visits from a CHN. Home visiting is central in preventive healthcare services, especially among the vulnerable population. In children under five years, it is plausible that nurse home visiting could lead to fewer acute care visits and hospitalization by providing early recognition of and effective intervention for problems such as jaundice, feeding difficulties, and skin and cord care in the home setting [ 19 ]. Home visiting emphasizes prevention, education, and collaboration as core pillars for promoting child, parent, and family well-being [ 20 ].

In Ghana, under the PHC initiative, communities are zoned or subdivided and have a CHN to manage each zone by conducting HVs, including a cluster of responsibilities mainly in the preventive care sectors [ 4 ]. As rightly identified, HV is one of the core mandates of the CHN. Most of the community members who had received more than one visit in a week lived close to the health facilities indicating that there are homes which have never been visited, and CHNs are not able to cover all homes in their catchment areas. Factors that deter the conduct of HVs by CHN ranged from community members' level of education, attitude, supervision challenges, lack of incentives, and lack of basic logistics to conduct HVs. It is imperative that CHNs HVs especially those with newborn children to assess the home environment and provide appropriate care interventions and education as it was reported that 2.8% of 2641 newborns who did not receive a HV were readmitted to the hospital in the first 10 days of life with jaundice and/or dehydration compared with 0.6% of 326 who did receive a HV [ 21 ]. CHNs need to be provided with the right tools including means of transport to reach “hard to reach” communities and homes to provide services.

In rural Ghana such as the AD, community members leave the home to their places of work or farms during the morning sessions and only return home in the evening or late afternoon. HVs (93.4%) were conducted between 9am and 2pm, while some homes (6.6%) were visited between 3pm and 6pm. One problem faced by this timing difference is further expressed when CHNs indicated that they did not meet people at home during HVs. It is important for CHNs to be wary of their safety in client's homes as they show enthusiasm to visit homes at any time, and they could meet significant others. Therefore, to ensure safety, it is important to cooperate with clients and their families [ 22 ] in providing these services especially outside the conventional working hours. The need to use alternative timing of visits is essential as it is known that client participation is required to determine the scope of quality and safety improvement work; in reality, it is difficult for them to participate [ 23 ]. Also, some respondents indicated the time spent during HVs was too short (32.7%), and others (24.5%) wished the CHNs could spend more time with them. Community members have problems they wished could be addressed by the CHNs during HVs, but because of the number of households compared to the limited number of CHNs available, the CHNs could not spend much time during HVs and the respondents were not satisfied with the services rendered. It is likely that services will be better implemented by households if the CHN spends much time with the household and together implements thought health activities. Amonoo-Lartson and De Vries reported that community clinic attendants who spent more time in consultation performed better [ 24 ].

CHNs (8.2%) indicated they could not visit all households that needed the home visiting services in their catchment areas. Home visiting nurses are required to be mindful of the time and environment where they are performing care [ 22 ], so that they can allow for maximum benefit to the community. This notwithstanding, some community members (26.7 %) were not available during the HVs. The determination of suitable time between the CHN and the client is critical in ensuring that a positive relationship is established for their mutual benefit. The interval associated with HVs varied from one community or a health centre to another, and this was planned based on the specific needs of each community or CHPS catchment zone. There is actually no one-size-fits-all approach to home visiting [ 20 ] as several strategies can be adopted in providing services. The number of weeks or months elapsing between the visits ranged from one week to four months. The ministry of Health Ghana per the PHC system encourages CHN to conduct at least one contact tracing and/or HV session within a week within their communities [ 25 ]. All CHNs indicated that in their catchment area, they conducted at least one HV in a week and sometimes even more depending on the exigencies of the time.

Various activities are expected to be conducted by CHNs during HVs. These activities include the provision of basic healthcare services such as prevention of diseases and accidents, disease surveillance, tracing of contacts of infectious disease, tracing of treatment defaulters such as tuberculosis, diabetes mellitus, and hypertension and management of minor ailments at home. Community members (62.3%) did not receive a minor ailment management during HVs. CHNs are expected to be equipped with requisite knowledge, tools, and skills to be able to conduct these services in the homes. Also, the level of care that can be identified as a minor ailment as per the guidelines of the Ministry of Health needs to be specific as community members had varied classification of minor ailments and the level of care to be provided. Home visitors have varying levels of formal education and come from a variety of educational backgrounds marked by different theoretical traditions and content knowledge [ 20 ]. Other jurisdiction HV nurses drew blood for bilirubin checks and set up home phototherapy if indicated; they provided breastfeeding promotion and teaching on feeding techniques and skin and cord care [ 19 ]. Also, CHNs are expected to be able to provide baby friendly home-based nursing care services during a visit to the clients' home. HV nurses should also discuss the schedule of well-baby visits and immunizations [ 19 ] with families.

Important challenges associated with the conduct of HVs were identified as a large catchment area, lack of basic logistics, lack of the reliable transportation system, uncooperative community members, inadequate staff, and “hard to reach” homes due to geographical inaccessibility. Health education, management of minor ailment, and vaccination or contact tracing were the activities carried out in the homes. Home visiting nurses are under pressure to complete a job within an allotted time frame, as determined by the contract or terms of employment [ 22 ]. Time pressure significantly contributes to fatigue and depersonalization, and adjustments to interpersonal relationships with nurse administrators can have notable alleviating effects in relation to burnout caused by time pressure [ 26 ]. CHNs (63.6%) identified inadequate equipment and financial constraints as challenges to HV. Given evidence suggesting that relationship-based practices are the core of successful home visiting [ 27 – 29 ], with a natural harmony between the home visitor and the community members to the home, she renders her services [ 20 ]. A report published by the National Academy of Sciences (1999) also identified staffing, family involvement, language barrier, and cultural diversities as some of the barriers to a HV [ 30 ].

Health education (87.9%) dominated the home visiting activities. Health education helps to provide a safe and supportive environment and also build a strong relationship that leads to long lasting benefits to the entire family [ 5 ]. Face to face teaching in the privacy of the home is an excellent environment for imparting health information [ 31 ]. The CHNs stated that health education, tracing of defaulters, and identification of new cases are the benefits and promotion factors for conducting HVs. This implies that there are other critical aspects of HV that CHNs neglect such as prevention of home accidents and ensuring a safe home environment and care for the aged. Early detection of potential health concerns and developmental delays, prevention of child abuse, and neglect are also other benefits and promotive factors of HV. HV helps to increase parents' knowledge, parent-child interactions, and involvement [ 5 ]. The conduct of HV was not reported among all community members as some community members (22.0%) in the AD indicated their homes have never been visited. This is, however, an improvement over the rate of HVs that was reported in the Assin district in Ghana [ 32 ]. In the Assin district, about 84% of the respondents said they gained benefits from HVs [ 32 ]. In this study, respondents who were visited indicated the CHNs just inspected their weighing card while giving them no feedback. CHNs should implement various interventions to ensure that community members directly benefit from health interventions that are implemented during HVs to reduce the consequences that are usually associated with poor access to healthcare services especially in poor rural communities such as the AD.

5. Conclusion

The activities carried out in the homes were mainly centred on health education, contact tracing, and vaccination. Health workers faced many challenges such as geographical inaccessibility, financial constraints, and insufficient equipment and medications to treat minor ailments. If HV is carried out properly and as often as expected, one would expect the absence of home accidents, child abuse, among others in the homes, and a reduction in hospital admissions.

The need for strengthening HV as a tool for improving household health and addressing home-based management of minor ailment in the district cannot be over emphasized. It is important to forge better intersectoral collaboration at the district level. The District Assembly could assist the District Health Management Team with transport to support HVs. In addition, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants should also be trained to identify and address health problems in the homes to complement that which is already conducted by healthcare professionals.

Acknowledgments

The authors wish to express their profound gratitude to the staff and district health management team of the AD of the Volta Region of Ghana for providing them with the necessary support and assisting in diverse ways to make this study possible. They thank their participants for the frank responses.

Abbreviations

Data availability, conflicts of interest.

The authors declare that they have no conflicts of interest.

Sheldon & Stoutner Family Law

Preparing for Home Visits During a Custody Evaluation

September 12, 2019 By Nicole Stoutner

By Launi Jones-Sheldon , Partner and Attorney

At any time in the custody evaluation process, an evaluator may decide a home visit is appropriate.  The purpose is to experience how a parent and child interact and view the condition of the home first-hand.

Typically, evaluators (or individuals they hire to assist them with home visits), plan to spend 2-3 hours observing a parent and child, as well as the child’s and parent’s interactions with other family members.   A home visit may include observing the parent and child cooking and eating a meal together, playing a game or with toys together, or working on homework together.   It also will include a review of the areas of the home in which a child may play, sleep, and eat.

Parents can practice the activities they plan to engage in with the children prior to the home visit.  I recommend parents start approximately two weeks before the planned visit.  This is not coaching, rather it is ensuring that he/she is presenting the best picture of their home and parent-child interaction.   It should not appear as though a parent has not even considered the evaluation or failed to complete prepare for the home visit.  In fact, the evaluator expects parents during home visits to put forth their best self and make good choices about the activities they choose in the child’s best interests.

Tips for the home visit:

• Parents should have the house and child’s room cleaned at least two weeks prior to the home visit, and keep it clean for the home visit. This includes ensuring there are age appropriate toys, clean clothes, clean diapers, trash/dirty diapers removed, food in the refrigerator, and age-appropriate childproofing throughout the house (plug covers, anchored furniture, medications or guns out of reach/access, and sharp edges covered).  If crawling children are present, consider cleaning the carpets/rugs.  It’s a good idea to display children’s artwork or successful school projects/tests such as on the refrigerator.  In addition, there should always be a pool fence or pool net, and there should not be animal feces indoors or excessively outdoors.
• At least two weeks in advance of a home visit, you should practice playing with children by engaging in several different games or using several different types of toys. Choose activities that the child enjoys and that are age appropriate.  Watching television or other electronic devices, or playing video games, is not advised.   If a child knows what to expect and has done the activity before, the child is more likely to be happy, comfortable, and cooperative when the evaluator is present.  Further, this sort of “practice” prevents frustration and confusion for the child.
• During the visit, speak proudly and positively about the child to the evaluator and in front of the child. However, be careful not to brag to the point that it appears unnatural or makes the child uncomfortable.
• During the visit, if asked or if appropriate, make positive complimentary statements about the other parent.  Do not speak about the case to the child or in the child’s earshot or view.  Again, be sure not to appear unnatural when making these statements.
• Refrain from whispering to the child in the evaluator’s presence and plan to speak in English unless permitted to use another language.
• Have a plan in place for how to discipline or correct the child if that becomes necessary during the home visit. Be careful and thoughtful in discipline or correction of the child.  At the same time, do not engage in discipline that is so out-of-character as to alert the child (and the evaluator) that you are “acting” and not being genuine.

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• Open access
• Published: 06 December 2021

Effects of home visits on quality of life among older adults: a systematic review protocol

• Yea Lu Tay   ORCID: orcid.org/0000-0002-0150-2075 1 ,
• Nurul Salwana Abu Bakar 1 ,
• Ruzimah Tumiran 1 ,
• Noor Hasidah Ab Rahman 1 ,
• Noor Areefa Ameera Mohd Ma’amor 2 ,
• Weng Keong Yau 3 &
• Zalilah Abdullah 1  

Systematic Reviews volume  10 , Article number:  307 ( 2021 ) Cite this article

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Home visiting services for older adults have been offered for decades to maintain and promote health and independent functioning, thus enhancing quality of life. Previous systematic reviews have provided a mixed picture of the benefits of home visiting programmes in older adults, primarily because of heterogeneity in study designs, targeted populations, and intervention strategies. These reviews may also become out of date; thus, an updated synthesis of relevant studies is warranted. Our objective is to perform a systematic review of recently published primary studies on the effectiveness of multi-professional home visits on quality of life among older adults.

We will perform a comprehensive search for studies investigating the effect of a multi-professional home visit approach on quality of life among older adults. We will conduct the literature search in selected electronic databases and relevant research websites from January 2010 onwards. We will include randomised controlled trials (RCTs), cluster randomised controlled trials (cluster RCTs), and observational studies that enrolled older adults without dementia over 60 years old, along with studies involving multi-professional preventive–promotive home visit approaches not related to recent hospital discharge. We will report our planned review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We will retrieve and record relevant data in a standardised data extraction form and evaluate the quality of the included articles using the Cochrane risk of bias tool and the quality assessment tool for studies with diverse designs (QATSDD). Where appropriate, outcomes will be pooled for meta-analysis using a random-effects model. The main outcomes include quality of life, incidence of falls, depression, dementia, and emergency department admissions.

This review may provide evidence for the effectiveness of home visits in improving older adults’ quality of life. It will potentially benefit health care professionals, policymakers, and researchers by facilitating the design and delivery of interventions related to older generations and improve service delivery in future.

Systematic review registration

PROSPERO CRD42021234531 .

Peer Review reports

Population ageing is a global phenomenon. Most individuals expect to live into their sixties and beyond. The world population of adults aged 60 years and over is expected to nearly double from 12 to 22% between 2015 and 2050 [ 1 ]. In Malaysia, 20% of the total population will be over 65 years old by 2030 [ 2 ]. A recent study indicated that the life expectancy of Malaysian older adults aged 65 years was 79.8 and 82.1 years for males and females, respectively [ 3 ]. Despite the national census statistics defining older adults as those over the age of 65, Malaysia adopted the United Nations’ definition, classifying older adults as those aged 60 years and above for policy development regarding the older adult population [ 4 ]. The older adult population has a multitude of health needs and challenges, along with a deteriorating quality of life (QoL) [ 5 ].

According to the World Health Organization (WHO), QoL refers to “an individual’s perception of life in the context of the culture and value system in which he or she lives and in relation to his or her goals, expectations, standards, and concerns” [ 6 ]. QoL linked to health concepts is defined as the value assigned to the duration of life, modulated by limitations, functional status, perceptions, and social opportunities, which are influenced by diseases, injuries, treatments, and health policies [ 7 ]. QoL is increasingly recognised as a focus for healthcare service delivery in the older adult population. It allows the healthcare providers and policymakers to measure the efficacy of health interventions and evaluate multi-sectoral public policies, which include health, social, community, and policy actions [ 8 ].

Numerous healthcare interventions have been designed and implemented with the goal of maintaining or improving QoL among older adults, and most studies indicate the importance of active ageing. These studies have demonstrated that QoL among older adults can be enhanced through low-cost interventions, such as physical exercise [ 9 , 10 , 11 ]. Besides, older adults utilising the home visiting services were shown to have a better QoL outcome [ 12 , 13 ].

Home visits are defined as visits to an individual’s home by professionals, which may include nurses, social workers, physicians, physiotherapists, occupational therapists, pharmacists and other specialists [ 14 ]. There are five types of home visiting services: palliative, rehabilitative, long-term maintenance, therapeutic, and preventive–promotive home visits [ 15 ]. Preventive–promotive home visiting services have been offered for decades with the goal of maintaining and promoting the health and independent functioning of older adults. In addition, these services aim to reduce admission to hospitals or nursing homes and the associated economic burden [ 16 , 17 ].

Home visits allow health professionals to evaluate possible problems in the living environment of homebound older adults, assess their physical and mental health status, provide older adults with professional support, and refer them to specialist care if needed [ 17 ]. By reducing the risk of functional deterioration, these strategies are primarily structured to enhance the health-related QoL (HRQoL) of older adults, increase the possibility of continued independent living, and delay mortality [ 18 ].

Home visits have been shown to positively affect patient care and provider attitudes as well as increased satisfaction among homebound older adults and providers [ 19 ]. A previous study demonstrated that preventive home visits may have positive effects on QoL of older adults [ 20 ]. However, the variability in the study designs, participants, and outcome measures has made comparisons difficult. Liimata et al. (2019) conducted a randomised controlled trial (RCT) measuring the effects of preventative multidisciplinary home visits on HRQoL of older adults living independently. The team, which consisted of a nurse, a physiotherapist, and a social worker, observed a significantly slower decline of HRQoL in the intervention group, but this effect diminished after the visits ended [ 20 ]. In a separate publication from the same study, preventive home visits resulted in an improved HRQoL without incurring additional healthcare costs [ 21 ]. An effective prevention method aids in supporting quality of life among older adults. In a review on preventive home visits for older adults, Mayo-Wilson et al. (2014) analysed 64 RCTs involving older adults without dementia from database inception until December 2012. The study yielded high-quality evidence for decreasing falls but low-quality evidence for quality of life [ 22 ]. Thus, although an RCT demonstrated promising results on home visits, a review of multiple RCTs failed to observe significant results. In addition, although multi-professional preventive home visit approaches with thorough evaluation and collaboration among healthcare professionals may be more beneficial than home visits by a single professional, few studies have focused on this multi-professional preventive home visit approach [ 20 , 23 , 24 ].

Multi-professional preventive home visit interventions involve coordination between several health care professionals towards shared goals. Effective communication among the team members is crucial when the members work within the boundaries of their expertise and subsequently discuss progress in group sessions [ 25 ]. Previous systematic reviews have provided a mixed picture of the benefits of multi-professional home visiting services for older adults. Stuck et al. [ 26 ] and Touringy et al. [ 14 ] suggested that the multi-professional approach with follow-up visits was effective in identifying the needs of the older adult population. However, Mayo-Wilson et al. [ 22 ] demonstrated the challenges of concluding that preventive home visits result in reliable benefits, primarily due to variability in the study designs, participants, and intervention strategies of the preventive home visits approach.

In Malaysia, home visiting services for the older adult population are delivered by a multidisciplinary team and are primarily provided by the Ministry of Health [ 27 ]. The home visiting services offered in Malaysia include home-based treatment, pharmacy counselling, rehabilitation, and palliative services, which aim to ensure continuity of care at home, reduce hospital readmission, and improve QoL [ 28 , 29 ]. According to the National Health and Morbidity Survey (NHMS) 2018, a national community survey for elderly health in Malaysia, 28.6% of older adults perceived themselves as having poor QoL, 14.1% reported having at least one fall in the 12 months prior to the survey, 8.5% were diagnosed with dementia, and 11.2% were at risk of experiencing depressive symptoms [ 30 ]. Poor QoL in Malaysian older adults was found to be associated with lower education, depression, food insecurity, reduced functional status, and a lack of social support [ 31 ]. Hence, we seek to examine preventive–promotive strategies that specifically prevent or reduce the risk of developing dementia, depression, and falls, with the ultimate aim of improving QoL among the older adult population.

To our knowledge, the most recent systematic review of primary studies examining the multi-professional preventive home visit approach for older adults included studies conducted up to December 2012 [ 22 ]. Because the older adult population is rapidly growing, the number of studies describing the home visit intervention is increasing, and the methodological and reporting quality of these studies is improving. Hence, a comprehensive systematic review which includes recent studies is needed to provide new evidence on the effectiveness of multi-professional preventive–promotive home visits in improving QoL among older adults. This review may serve as a guideline for the healthcare professionals, policymakers, researchers, and institutions in designing and delivering interventions for older adults in future. Aligning health systems with the needs of the older adult population may help to promote healthy ageing in Malaysia in the long term.

This study aims to systematically assess the effect of a multi-professional home visit approach on QoL among older adults.

The present protocol has been registered within the PROSPERO database (registration number CRD42021234531) and is being reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement [ 32 , 33 ] (see checklist in Additional file 1).

Eligibility criteria

Types of studies.

Randomised controlled trials (RCTs), cluster randomised controlled trials (cluster RCTs), and observational studies (such as cohort, case-control, and cross-sectional studies) will be included. Quasi-randomised controlled trials (quasi-RCTs), which are often associated with a high risk of bias, and cross-over studies will be excluded. Case reports, guidelines, protocols, and short communication will also be excluded.

We will only include studies examining the older adults without dementia aged 60 years and above who reside in their own homes and receive treatment at primary care outpatient departments. We will exclude studies that involve older adults living in retirement homes or nursing homes.

Types of interventions

We will include studies that aim specifically to assess the following interventions:

Home visits which aim to prevent or reduce risks related to ageing

Home visits which utilise at least two of the following multidimensional approaches: medical, functional, psychosocial, and environmental evaluation of problems and resources, resulting in specific recommendations for solving observed problems and preventing new ones.

Types of outcome measures

Primary outcomes.

We will measure QoL using validated scales such as the WHO QoL Questionnaires, WHOQoL-BREF [ 34 ] and WHOQoL-OLD [ 35 ], the 19-item Control, Autonomy, Self-Realisation and Pleasure (CASP-19) questionnaire [ 36 ], the Older People’s Quality of Life (OPQoL) questionnaire [ 37 ], and the 36-item Short Form Health Survey (SF-36) [ 38 , 39 ].

Secondary outcomes

We will also analyse the effects of home visit interventions on the incidence of falls, depression, dementia, and emergency department admissions.

Exclusion criteria

We will exclude studies that involve follow-up visits for recent hospital discharge and studies targeting people with one specific illness.

Information sources

A comprehensive systematic electronic search will be conducted using these databases: PubMed, Ovid MEDLINE (R), the Cochrane Library, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, ClinicalTrials.gov , the metaRegister of Controlled Trials, the Turning Research into Practice (TRIP) database, Open Grey, High Wire, the National Institute for Health and Care Excellence (NICE), and the National Institutes of Health (NIH). The search will be limited to English language articles published from January 2010 onwards.

In addition, cross-referencing will be performed, whereby the reference lists of articles will be scanned for relevant studies. We will hand-search Malaysian quality initiative or health systems project reports in the libraries of the Institute for Medical Research (IMR), Institute for Health Management (IHM), Institute for Health System Research (IHSR), Institute for Public Health (IPH), and Ministry of Health, Malaysia.

Search strategy

The search strategy will be based on the key components of the research question: population, interventions, and outcomes. It will include a mix of medical subject headings (MeSH) terms and free-text terms in the title and abstract search fields of the databases. The keywords will be related to the participants (e.g., aged, senior, older, elder, and geriatric), home care (e.g., house calls, home visits, and home care), and the outcomes (e.g., quality of life and accidental falls). Examples of the search strategy are presented in Additional file 2.

Selection of studies

Two review authors will examine the titles and abstracts independently and will exclude all irrelevant studies. Two review authors will independently retrieve and screen the full text of potentially relevant articles and identify those that meet the eligibility criteria. These steps will be recorded in an Excel table along with the reasons for study exclusion. To avoid duplication, data will be identified from the main source. Any disagreements that arise will be resolved through discussions with a third author. A PRISMA flow chart showing details of studies included and excluded at each stage of the study selection process will be provided [ 33 ].

Data extraction

Two reviewers will independently retrieve and record data in a data extraction form. Any disagreements will be resolved through discussion with the third reviewer. The data extraction form will include the following variables:

General information: title, first author, publication year, and country

Methods: study design, study duration, sample size, and mean age of the sample

Types of intervention: visitors’ professional group, number of visits, length of visits

Outcome measures:

○ Primary outcome: QoL (characteristics of the scales used to measure QoL)

○ Secondary outcomes: incidence of falls, depression, dementia, and emergency department admissions

Quality assessment

Two reviewers will evaluate the possible risk of bias for each study independently. Any disagreements will be discussed with the third reviewer. We will evaluate the RCT and cluster RCT articles for the methodological quality using the Cochrane risk of bias tool (RoB 2.0) [ 40 ]. We will categorise the risk of bias as low, high, or unclear in each of the following domains: allocation concealment, random sequence generation, blinding of outcome assessment, selective outcome reporting, incomplete outcome data, and other sources of bias.

The quality assessment tool for studies with diverse designs (QATSDD) [ 41 , 42 ] will be utilised to assess mixed-method studies. There are 14 QATSDD evaluative indicators for quantitative studies. Each indicator will be measured on a 4-point Likert scale as follows: 0 (not at all), 1 (very slightly), 2 (moderate), and 3 (complete). The maximum score of this tool is 42. The quality of a study is rated as ‘high’ if the score is over 75%, ‘good’ if it is between 50 and 75%, ‘moderate’ if it is between 25 and 50%, and ‘poor’ if it is below 25%.

Data synthesis and analysis

If the studies are sufficiently homogenous in terms of population, interventions, and outcomes, the results will be pooled, and a meta-analysis using a random-effects model will be conducted. Where possible, dichotomous data will be presented as relative risks (RRs) with 95% confidence intervals (CIs). Continuous data will be expressed as mean differences (MDs) or standardised mean differences (SMDs) (when the outcome is measured using several scales or instruments) with 95% CIs [ 43 ]. If the study characteristics are substantially different, the results will be analysed in the following subgroups, if data are available:

Participant’s age: 60–79, ≥80

Visitors’ professional group

We will interpret the heterogeneity and variability of the included studies in relation to population, interventions, outcomes, and methods. When meta-analysis is attempted, heterogeneity will be evaluated by forest plots to assess whether the CIs overlap. In addition, heterogeneity among the included studies will be measured using the chi-square ( χ 2 ) test and I 2 statistic. A small p value ( p < 0.1) for the χ 2 test and an I 2 of 50% or higher indicate moderate to substantial heterogeneity [ 44 ].

If meta-analysis is not possible, a narrative will be developed to summarise differences. We will present the data in a summary table outlining the content of the included primary studies (the number of participants, study population, description of interventions), as well as the results, conclusions, and quality ranking of studies.

Meta-bias(es)

We will assess publication bias using the Tandem method. If possible, the potential for reporting bias will be further explored using a funnel plot. A linear regression test will be performed to examine the degree of publication bias. Publication bias is significant if the p-value is less than 0.1.

Confidence in cumulative evidence

The quality of the evidence synthesised in this review will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology [ 45 ]. This methodology involves the evaluation of the evidence quality for each outcome across the domains of risk of bias, consistency, directness of evidence, precision of effect estimates, and publication bias, resulting in the following grades for each outcome: high, moderate, low, or very low [ 17 , 46 ].

This review may serve as evidence to support effective interdisciplinary home visits that can improve health-related QoL among older adults. This will potentially benefit policymakers and healthcare managers in planning for an efficient resource utilisation and evidence-based policy designs catered to older adults’ health. Healthcare professionals and implementers will be able to deliver health programmes and interventions suited to the needs of the older adult population. Researchers and other institutions will gain knowledge of multiple health interventions. In addition, recognising international practices will provide information to policymakers regarding strategies to improve quality of care in future.

This review has potential limitations. Our search strategy may miss sources of information available in languages other than the English language. In addition, we anticipate that the review will face challenges due to the heterogeneous nature of the study design, particularly in interventions and outcomes measures, which may limit the interpretability and comparability of results.

Protocol amendments

Any amendments to this protocol in the carrying out of this systematic review will be documented and reported in both the PROSPERO register and any subsequent publications.

Dissemination plans

The findings of this systematic review will be disseminated through publication in peer-reviewed journals and via relevant conferences. In addition, the results will also be shared with potential stakeholders, such as the Ministry of Women, Family and Community Development and the Family Health Development Division under the Ministry of Health Malaysia.

Availability of data and materials

Not applicable.

Abbreviations

Confidence interval

Cluster randomised controlled trials

Health-related quality of life

Medical subject headings

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Quality assessment tool for studies with diverse design

Quality of life

Quasi-randomised controlled trials

Randomised controlled trials

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Acknowledgements

We would like to express our appreciation to the Director General of Health Malaysia for his permission to publish this systematic review protocol. We would also like to thank the Director of the Institute for Health Systems Research, National Institutes of Health Malaysia for her permission to conduct this review.

The authors declare that they have received no specific funding for this work.

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Institute for Health Systems Research, National Institutes of Health, Ministry of Health Malaysia, 40170, Shah Alam, Selangor, Malaysia

Yea Lu Tay, Nurul Salwana Abu Bakar, Ruzimah Tumiran, Noor Hasidah Ab Rahman & Zalilah Abdullah

Institute of Biological Sciences, Faculty of Science, Universiti Malaya, 50603, Kuala Lumpur, Malaysia

Noor Areefa Ameera Mohd Ma’amor

General Medical Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586, Kuala Lumpur, Malaysia

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Contributions

Conceiving the protocol: YLT, NSAB, and ZA. Designing the protocol: YLT and NSAB. Coordinating the protocol: ZA. Designing search strategies: YLT, NSAB, and NAAMM. Writing the protocol: YLT, NSAB, RT, NHAR, and ZA. Providing general advice on the protocol: WKY. The authors read and approved the final manuscript.

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Correspondence to Yea Lu Tay .

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This systematic review protocol was registered with the National Medical Research Register (NMRR-20-1810-56054), Ministry of Health Malaysia. Ethical approval was sought from the Health Medical Research Ethics Committee (MREC), Ministry of Health Malaysia, on 9 September 2020.

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Tay, Y.L., Abu Bakar, N.S., Tumiran, R. et al. Effects of home visits on quality of life among older adults: a systematic review protocol. Syst Rev 10 , 307 (2021). https://doi.org/10.1186/s13643-021-01862-8

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What Is Home Visiting?

Early childhood home visiting is a service delivery strategy that matches expectant parents and caregivers of young children with a designated support person—typically a trained nurse, social worker, or early childhood specialist—who guides them through the early stages of raising a family. Services are voluntary, may include caregiver coaching or connecting families to needed services, and provided in the family's home or another location of the family's choice. 

Home visiting is a holistic, two-generation approach.

Home visiting views child and family development from a holistic perspective that encompasses child health and well-being, child development and school readiness, positive parent-child relationships, parent health and well-being, family economic self-sufficiency, and family functioning. A two-generation approach with a lengthy history , home visiting delivers both parent- and child-oriented services to help the whole family thrive. Although services differ across models, home visitors typically—

Gather Family Information to Tailor Services

• Screen caregivers for issues like postpartum depression, substance use, and domestic violence
• Screen children for developmental delays

Provide Direct Education and Support

• Provide knowledge and training to make homes safer
• Promote safe sleep practices
• Offer information about child development

Make Referrals and Coordinate Services

• Help pregnant women access prenatal care
• Check to make sure children attend well-child visits
• Connect caregivers with job training and education programs
• Refer caregivers as needed to mental health or domestic violence resources

Discover more in our Primer and At a Glance resources.

Home visiting outcomes are supported by research.

Research shows that voluntary home visiting programs help improve infant and maternal health, develop safe homes and nurturing relationships to prevent prevent child abuse and injury or mortality, support early learning and long-term academic achievement, and make referrals and coordinate services. Studies have found a return on investment of $1.80 to $5.70 for every dollar spent. This strong return on investment is consistent with established research on other types of early childhood interventions.

Learn more about the benefits .

Many models are evidence based or on the path to becoming so. 

Programs choose from a variety of models to implement with families, each suited to differing community needs, target obstacles, and available resources. The Home Visiting Evidence of Effectiveness (HomVEE) project administered by the U.S. Department of Health and Human Services has issued a set of criteria for evidence of model effectiveness. Models that meet criteria are deemed evidence based. NHVRC surveys evidence-based and emerging models at the national, state/local, and tribal levels annually to provide a comprehensive assessment of the landscape in our Yearbook .  

Visit our model profiles for details on individual models.

Home Visiting Primer READ

Stay up to date on the latest home visiting information.

Coding for E/M home visits changed this year. Here’s what you need to know

CPT has revised codes for at-home evaluation and management (E/M) services as of Jan. 1, 2023. Services to patients in a private residence (e.g., house or apartment) or temporary lodgings (e.g., hotel or shelter) are now combined with services in facilities where only minimal health care is provided (e.g., independent or assisted living) in these code families:

Home or residence E/M services, new patient

• 99341, straightforward medical decision making (MDM) or at least 15 minutes total time,

• 99342, low level MDM or at least 30 minutes total time,

• 99344 (code 99343 has been deleted), moderate level MDM or at least 60 minutes total time, 

• 99345, high level MDM or at least 75 minutes total time.

Home or residence services, established patient   

• 99347, straightforward MDM or at least 20 minutes total time,

• 99348, low level MDM or at least 30 minutes total time,

• 99349, moderate level MDM or at least 40 minutes total time,

• 99350, high level MDM or at least 60 minutes total time. 

Select these codes based on either your level of medical decision making or total time on the date of the encounter , similar to selecting codes for office visits . The E/M codes specific to domiciliary, rest home (e.g., boarding home), or custodial care (99324-99238, 99334-99337, 99339, and 99340) have been deleted, and the above codes should also be used in those settings.

When total time on the date of the encounter exceeds the threshold for code 99345 or 99350 by at least 15 minutes, you can add code 99417 to report prolonged services. The exception to this is for patients with Medicare. For those patients, report prolonged home or residence services to Medicare with code G0318 in addition to 99345 (requires total time ≥140 minutes) or 99350 (requires total time ≥110 minutes). Code G0318 is not limited to time on the date of the encounter, but includes any work within three days prior to the service or within seven days after.

Services provided in facilities where significant medical or psychiatric care is available (e.g., nursing facility, intermediate care facility for persons with intellectual disabilities, or psychiatric residential treatment facility) are reported with codes 99304-99310 .

— Cindy Hughes, CPC, CFPC

Posted on Jan. 19, 2023

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Evaluation of home visits using a nursing process approach

• PMID: 2348220
• DOI: 10.1207/s15327655jchn0702_3

Few tools for home visit evaluation of students exist in current nursing literature. Therefore, a tool was developed that utilizes a nursing process framework to measure essential nursing behaviors in the home. Incorporated into the tool are unique facets of community-oriented nursing practice, such as home environment assessment, family-oriented nursing diagnoses, bag technique, and contracting. The tool is a two-page form designed to evaluate pre-visit, onsite, and post-visit nursing activities. The tool has been refined using empirical data from clinical experiences with over 200 students in community health nursing.

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• Nursing Process*
• Personnel Management*

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Parent/Child Observations and Home Visits During Custody Evaluations

Robert J. Loveland, Ph.D.

When a new client and I are discussing the custody evaluation process during that parent’s first appointment, two of the most frequently asked questions are, “What will happen during the parent/child observation?” and, “Will you be doing a home visit?” These two questions and the anxiety in the parent’s voice are a sure sign that this particular parent has done some Internet research because parent/child observations and home visits are frequently mentioned on websites devoted to custody and family law evaluations. Parent/child observations refer to an evaluation technique where parents are seen jointly with their children, and they are observed performing a structured task of some sort (perhaps an arts and crafts project), or they are simply allowed to play and interact with each other in some unstructured fashion. Home visits are just that; the evaluator spends time in the family home to conduct interviews, see the residential setting, and perhaps conduct a parent/child observation. Custody evaluators frequently use these techniques as part of the overall evaluation process, although I have spoken to many other evaluators who believe as I do that the techniques are not particularly helpful.

Psychologists who conduct custody evaluations tend to generally follow the guidelines that are espoused by the American Psychological Association. These  Guidelines for Child Custody Evaluations in Family Law Proceedings mention parent/child observations or home visits in only vague terms by stating in Section 10 that, “Direct methods of data gathering typically include such components as psychological testing, clinical interview, and behavioral observation.”  However, other professional organizations encourage these evaluation techniques in much stronger terms. One of those professional organizations is the Association of Family and Conciliation Courts (AFCC), a much-respected organization to which I belong. The AFCC has published a non-binding set of suggestions for custody evaluators, the  Model Standards of Practice for Child Custody Evaluation . An entire section, Section 10, of these standards is devoted to “Observational-Interactional Assessment” of parents and children. In that section, the AFCC standards state that,  “Observations of parents with children shall be conducted in order that the evaluator may view samples of the interactions between and among the children and parents, and may obtain observational data reflecting on parenting skills and on each parent’s ability to respond to the children’s needs. In the course of such observations, evaluators shall be attentive to (1) signs of reciprocal connection and attention; (2) communication skills; (3) methods by which parents maintain control, where doing so is appropriate; (4) parental expectations relating to developmentally appropriate behavior; and, (5) when parents have been asked to bring materials for use during the interactive session, the appropriateness of the materials brought.”  As an experienced custody evaluator I do not believe that any such thing can actually be measured in any comprehensive fashion during a parent/child observation or home visit (unless an evaluator were to move in with the family for a few months), and these are the types of statements that parents read on the Internet that make them very nervous. Parents who are engaged in a custody evaluation are understandably concerned about parent/child observations and home visits. They are worried about how they might be seen or how their home might be viewed, and they tend to be even more worried about what the evaluator might think if little Johnny or Susie has a particularly bad day on the day of the appointment.

For any parent who might be reading this article in preparation for coming to work with me in a custody evaluation with your children, allow me to lay aside your fears regarding the manner in which parent/child observations and home visits fit into my own practice. I do sometimes conduct parent/child observations, particularly with younger children, and I have been invited into hundreds of family homes for professional visits. However, the information that is gathered from these family contacts is used in the most careful and conservative terms. At no point is this information used to make global or broad assumptions about some of the crucial family characteristics mentioned in the AFCC standards. In my entire career I have never had an evaluation tip one way or the other based on information gathered from an observation or a home visit. Allow me to explain.

As a licensed clinical psychologist who specializes in family law matters, I am duty bound to employ evaluation techniques that are as reliable and as valid as possible. Both the A.P.A. Guidelines and the A.F.C.C. Standards clearly mention the need for  reliable  and  valid  measurement procedures.  Reliability  and  validity  are common everyday words but they are also mathematical and statistical terms that have special meaning to psychologists. In the psychological world, if an evaluation technique is  reliable  it means that the same result is likely to occur every time that the technique is employed. Reliability refers to the consistency of a measurement tool. If an evaluation technique is  valid , it means that the technique is actually measuring what it is supposed to be measuring. A measurement tool can be reliable but not valid and it can be valid but not reliable. Psychologists hope to use evaluation techniques that are 100% reliable and 100% valid, but that is not typically possible in human affairs. It does happen in other scientific areas. For example, if I am holding a bowling ball and let it go, it will reliably and consistently drop to the floor 100% of the time, and the fall itself will be an accurate and valid demonstration of the power of gravity. Human behavior is a bit more complicated than gravity, so psychologists often employ measurement tools for human characteristics with reliability and validity ratings hovering around 80% or so, and sometimes slightly better. That means that psychologists must use techniques that are only “basically reliable” or “basically valid”, but we do the best we can with the evaluation tools themselves combined with the wisdom that comes from years of experience with people.

When these concepts are applied in a realistic fashion to parent/child observations and home visits, it is clear to me and to other professionals in this field that these evaluation techniques are neither reliable nor valid. I could spend an hour or so observing a father and his child on 10 different days and still see something different every time. This would not be a reliable measurement of anything. I could do the same with a mother and her child, and I am still only measuring how a nervous mother might be relating to her child in a strange environment with a relative stranger. This would not be valid regarding the real quality of the parent/child relationship. Moving the parent/child observation to the home environment does nothing to improve the odds. In other words, my observing a parent and a child together in my office or in their home in either a structured or unstructured fashion might be interesting and even fun, but the observation itself cannot reliably or validly be used to form broad conclusions regarding the issues related to custody and parenting plan decisions. Consequently, even if I have spent significant time with a parent and child together, none of my reports will ever draw conclusions that are based solely on what I may or may not have observed.

This latter point is why I take issue with the lofty respect that is accorded the parent/child observations as an evaluation tool by some legal and mental health professionals who perhaps have not given this issue much thought. For example, some evaluators spend relatively little time observing a parent and child together, and then they make broad statements in their reports that could not possibly be supported by what they might have observed. As an experienced evaluator I have been asked by attorneys to review a very large number of reports from other evaluators where a brief parent/child observation is used as the basis for forming broad and general conclusions about such concepts as parent/child bonding and attachment, discipline approaches and parenting style, general parenting skill, and even personality issues of parent and child. This is not proper, nor is it reliable or valid. I would imagine that there are instances where something absolutely extraordinary happens during an observation that is worthy of note, but an occasional or unusual event does not support the misuse and over-interpretation of what can be learned from watching a parent play checkers with their child in an evaluator’s office.

In addition, psychologists are duty bound to avoid as many sources of evaluation bias as possible. Parent/child observations and home visits are both rampant sources of potential bias in several areas. The AFCC mentions only one by warning of observer effects:  “Evaluators shall be mindful of the fact that their presence in the same physical environment as those being observed creates a risk that they will influence the very behaviors and interactions that they are endeavoring to observe.”  There are many more potential biases than just this one.

That being said, these two evaluation techniques certainly have a place in my practice, but they are both used in a limited, down-to-earth, and child-friendly fashion. Their use varies from family to family, and they are only employed when circumstances justify that some reasonably reliable and valid data might be the end result. I do spend a great deal of time with parents and young children together in my office or playroom. This is done to avoid any stress for a young child rather than as a specific evaluation tool. I spend a good deal more time interviewing children on their own, provided that they are old enough and secure enough to separate from their mom or dad and participate in their own interview. Children universally report to their parents that they had a great time, and the information that is gathered is much more meaningful and useful than anything that I have ever gathered during a parent/child observation. With older children, and certainly with adolescents, interviewing them alone is infinitely more reliable and valid than placing them in an awkward situation with their mom and dad, particularly when the divorce process frequently heightens emotions. The custody evaluation process involves gathering family information from a wide variety of sources and employing a variety of measurement tools. Parents who involve themselves with my practice can be assured that regardless of what they might have read about evaluations on the Internet, parent/child observations or a home visit will not become a nerve-wrecking experience for either parent or child.