Home visit assessment strategies: a scope review

Abstract

Objective

To explore the literature related to home visit assessment strategies in early childhood visiting programs.

Methods

A scope review based on the methodology proposed by the Joanna Briggs Institute, which used PubMed, Web of Science, Scopus, CINAHL, Embase, Virtual Health Library for search. There was addition of studies from other sources. After review by two independent reviewers of the inclusion criteria, 19 studies were selected to compose the sample.

Results

Home visiting programs for early childhood use analysis of visitor notebooks, interview with participants, and application of measurement tools as strategies to assess the visit.

Conclusion

The review has brought a range of approaches that can be adopted according to the purpose of each program and availability of resources. They lack proven effectiveness strategies, as well as validated tools and methods.

House calls; Program evaluation; Child development; Primary health care; Comprehensive health care

Resumo

Objetivo

Explorar a literatura relacionada às estratégias de avaliação da visita domiciliar nos programas de visitação para a primeira infância.

Métodos

Revisão de escopo baseada na metodologia proposta pelo Instituto Joanna Briggs. Foram analisadas as seguintes bases: PubMed, Web of Science, Scopus, CINAHL, Embase, Biblioteca Virtual da Saúde e acrescentados estudos de outras fontes. Após revisão por dois revisores independente quanto aos critérios de inclusão, foram selecionados 19 estudos para compor a amostra.

Resultados

Os programas de visita domiciliar para a primeira infância utilizam a análise dos cadernos de anotação do visitador, a entrevista com participantes e a aplicação de instrumentos de medida como estratégias para avaliar a visita.

Conclusão

A revisão trouxe uma gama de abordagens que podem ser adotadas segundo o objetivo de cada programa e a disponibilidade de recursos. Carecem de estratégias efetividade comprovadas, além de instrumentos e métodos validados.

Visita domiciliar; Avaliação de programas e projetos de saúde; Desenvolvimento infantil; Atenção primária à saúde; Assistência integral à saúde

Resumen

Objetivo

investigar la literatura relacionada con las estrategias de evaluación de visitas domiciliarias en los programas de visitas en la primera infancia.

Métodos

revisión del alcance basada en la metodología propuesta por el Instituto Joanna Briggs. Se analizaron las siguientes bases: PubMed, Web of Science, Scopus, CINAHL, Embase, Biblioteca Virtual da Saúde y estudios de otras fuentes. Luego de la revisión realizada por dos revisores independientes sobre los criterios de inclusión, se seleccionaron 19 estudios para componer la muestra.

Resultados

los programas de visitas domiciliarias en la primera infancia utilizan un análisis de las notas del visitador, la entrevista con participantes y la aplicación de instrumentos de medida como estrategias para evaluar las visitas.

Conclusión

la revisión trajo una gama de enfoques que pueden ser adoptados según el objetivo de cada programa y la disponibilidad de recursos. Carecen de estrategias de efectividad comprobadas, además de instrumentos y métodos validados.

Visita domiciliaria; Evaluación de Programas y proyectos de salud; Desarrollo infantil; Atención primaria de salud; Atención integral de salud

Introduction

The social and economic costs of inaction in early childhood are high. About 250 million children in low-income and middle-income countries suffer from poor development due to poverty.¹ Furthermore, one in three pre-school children living in poor and developing countries is below the basic milestones in their cognitive or socio-emotional development.²

Although there is consistent evidence that home visiting programs are effective interventions to promote child development,³in poor and developing countries few interventions have been expanded and assessed, and access is still limited.⁴

Appropriate encouragement coupled with responsive care at this stage have long-lasting results and impact throughout the child’s life course.⁵ Such outcomes are not confined to the family environment, since early childhood companies gain in formation of human capital in full development and, therefore, are prepared for the challenges of a demanding and constantly changing labor market.⁶

Home visits have been widely adopted as a delivery tool for early childhood programs. Its power is to enable a longitudinal care and consider the link with the visiting professional fundamental to achieve the expected results.⁷ Furthermore, home is an ideal environment for the implementation of parenting interventions, as it is a comfortable and convenient place for parents with young children to receive professional support.⁸

Therefore, assessing home visits to understand visit strategies and patterns of family engagement is an important tool to achieve the programs’ objectives.⁹ The effects of a program are more robust when interventions are well implemented, ie when a high degree of fidelity is achieved.¹⁰,¹¹ When the results of a program do not reach what is expected, it is investigated how the services were implemented in relation to the proposed one and it is argued if the program would have worked better if it had been operated correctly.¹²

Moreover, such information may also be used for professional development, supervisory activities and formulation of training courses. Therefore, tools for assessing home visits have great relevance in the consolidation of large-scale effective programs.¹³

In this sense, there is a shortage of studies that clarify what methodologies are adopted for home visit assessment in visiting programs that can be trusted and that serve the programs’ purposes. Therefore, this scope review sought to explore the literature related to home visit assessment strategies in early childhood visiting programs.

Methods

This is a scope review that aimed at mapping concepts that support a certain knowledge field, with several types of available sources and based on a comprehensive literature coverage to identify research gaps in the existing literature.¹⁴

In the present review, the PCC strategy was used to formulate the research question. “P” was used for population/participants, “C” for the concept to be investigated, “C” for context. Adjusting the study object to the PCC strategy, there is as guiding question: What are the strategies for assessing home visits in early childhood visiting programs? “Home visits” correspond to the population, “assessment strategies” is the concept and “early childhood visiting programs” is the research context.

There was inclusion of studies that consider home visits as the main service delivery strategy; that demonstrate some strategy adopted to assess home visits; and a home visit program that operates in at least one of the eight most important domains for early childhood: child health; child development and school readiness; self-sufficiency of the family; social network; maternal health; positive parenting practices; reduction of child maltreatment; reduction of juvenile delinquency, family violence and crime.³ Adoption criteria were those with group approaches, family support by telephone or other digital platforms, and there is no clarity that the program works in at least one of the most relevant domains for early childhood.

This scope review included quantitative or qualitative primary studies and review studies that met the inclusion criteria for participants, concept, and context. Moreover, texts and opinion articles, theses, dissertation, visiting programs reports, and technical documents were also considered for inclusion in this review. Studies published in English, Spanish, and Portuguese were included. There was no time limit for study selection.

Search strategy

Search strategy and the entire review process was based on the Joanna Briggs Institute’s review methodology.¹⁵ Therefore, search strategy step was used in this review. A first stage of research was limited to MEDLINE for analysis of titles, abstracts and descriptors used in the articles. A second step of the research used all of the identified keywords and descriptors in all of the study’s databases. In a third step, there was addition of studies.

Database search was conducted between May and July 2018 by two independent reviewers, and included studies of the following databases through June 2018: MEDLINE, CINAHL, Web of Science, Virtual Health Library, Scopus, Embase. Unpublished studies search included the Academic Google, USP Theses Bank, National Health Service - NHS, U.S. Department of Health and Human Service. The search strategy adopted in each database, descriptors/keywords used and references retrieved and selected are described in chart 1.

Chart 1
Databases, search strategy, and references

Information resource	Search strategy	References retrieved	References selected by title/abstract
MEDLINE	“House Calls”[Mesh] AND “Early Intervention (Education)”[Mesh]) AND “Health Care Quality, Access, and Assessment”[Mesh]	18	13
	“House Calls”[Mesh] AND “Quality of Health Care”[Mesh] AND child development	161	33
Web of Science	home visit quality AND early intervention	245	25
	home visit program AND quality AND child development	109	31
Scopus	“home visit” AND fidelity	40	6
CINAHL	home visiting programs AND fidelity	19	03
	home visits AND early intervention	277	28
Embase	“home visits” AND quality AND “child development”	13	02
Virtual Health Library	“visita domiciliar” [DeCS] AND “desenvolvimento infantil” [DeCS]	22	01

Study selection

The search strategy identified a total of 904 studies, and a further 12 were included from other sources. After excluding 52 duplicate citations and 710 studies that did not meet the inclusion criteria by reading the title, 142 studies were selected for reading the abstract and determining the inclusion criteria relevance. Subsequently, 41 articles were excluded, since they did not meet the inclusion criteria. Finally, a total of 101 studies were read, of which 82 were excluded and 19 were included in the review. The research results are presented in a PRISMA flowchart (Figure 1). All identified studies were grouped and exported to Mendeley^®, and duplicates were removed. Titles and abstracts were analyzed by two independent reviewers for assessment in relation to the inclusion criteria for the review. Studies that met the established criteria were fully retrieved and their details were imported into SUMARI^® (research support software from the Joanna Briggs Institute). The selected studies’ full text was retrieved and assessed in detail in relation to the inclusion criteria, and those that did not meet were excluded.

Figure 1
PRISMA study selection flowchart and inclusion process

Data extraction

Data were extracted from articles included in the scope review by two independent reviewers using the Joanna Briggs Institute’s standardized data extraction tool in the SUMARI^® software. Extracted data included specific details about population, concept, context, study methods and key findings relevant to the review objective.

Results

Characteristics of studies

The included studies were published after 2001, and almost half of them have been published since 2012, which demonstrates a relatively recent interest of the visiting programs in using home visit as assessment strategy. As for the country where the study was conducted, the United States concentrated the majority of the studies (n=14) because the country has a wide network of services focused on early childhood. Regarding study participants, families (n=8) were the object of assessment of the visit, followed by visitors/supervisors (n=6). Finally, the visit was assessed within the program (n=4), as described in chart 2.

Chart 2
Characterization of publications regarding author, year, objective, study design, participants and country of origin

Authors/Year	Objective	Study design	Participants	Country
Leer J, Boo F, Expósito A, Powell C (2016)(16)	To assess home visit in the areas of content, relationships and activities carried out at home.	Observational during home visit by measuring tool	Families (n= 40)	Peru, Brazil, Jamaica, Bolivia, Nicaragua, Panama and Ecuador
Paulsell D, Boller K, Hallgren K, Esposito A (2010)(17)	To present information about elements adopted to assess home visit.	A theoretical study	-	United States
Korfmacher J, Laszewski A, Sparr M, Hammel J (2012)(18)	To develop a tool for assessing the quality of home visiting programs for early childhood.	A methodological study	Visiting Programs (n- 11)	United States
Hallgren K, Boller K, Paulsell D (2010)(19)	To assess home visit in content and quality domains.	An observational through filming and use of measuring tools.	Home visits (n=35)	United States
Watson C, Bailey A, Storm K (2016)(20)	To use reflexive practice to assess the quality of home visits and training of visitors.	Use of questionnaire and interview with visitors and supervisors.	Supervisors (n- 26) and visitors (n- 66)	United States
Black K, Wenger M, O’Fallon M (2015)(10)	To develop a tool that incorporates a longitudinal model for the assessment and development of nurse visiting skills.	A methodological study	Visiting nurse and supervisors	United States
Ammerman R, Putnam F, Kopke J, Gannon T, Short J, Ginkel J, Clark M, Carrozza M, Spector A (2007)(21)	Describes the use of quality indicators for home visit assessment.	A methodological study	Visitors, supervisors and support staff	United States
Vaughn L; Forbes J; Howell B (2009)(22)	To assess home visit through the participation of families.	A qualitative study that used photovoice and content analysis.	Families (n= 07)	United States
Saıa T, Lerner E, Greacen T, Simon-Vernier E, Emer A, Pintaux E, Guedeney A, Dugravier R, Tereno S, Falissard B, Tubach F (2012)(23)	To assess home visit fidelity through the notebooks of visits.	A qualitative study that carried out analysis of in visit notebooks content.	Families (n= 105)	France
Robling M (2014)(24)	To assess home visit in the content domain addressed.	A qualitative study that recorded home visit and estimated the time spent in each theme of the curriculum of the program.	Families (n= 139)	England
Roggman L, Cook G, Innocenti M, Norman V, Boyce L, Peterson C (2016)(9)	To assess the quality of the domiciliary visit in the relationship domain-visitor-caregiver-child.	A quantitative study by filming the visit and using the measuring tool	Families (n= 71)	United States
Drummond J, Weir A, Kysela G (2002)(25)	To assess the practices used in home visit.	A qualitative study through the analysis of notebooks for visits.	Families (n= 50)	Canada
Korfmacher J, Sparr M, Chawla N, Fulford J, Fleming J (2012)(26)	To assess the quality of the domiciliary visit in the relationship domain-visitor-caregiver-child.	A quantitative study by filming the visit and using the measuring tool	Families (n= 85)	United States
Brand T, Jungmann T (2012)(27)	To assess home visit in the content domain addressed.	A qualitative study through analysis of visit notebooks that analyzed the time spent in each content and the materials used in the visit.	Visitors (n= 60)	Germany
Roggman L, Boyce L, Cook G, Jump V (2001)(28)	To assess content and quality home visits.	A quantitative study using a measuring tool.	Families (n= 49)	United States
Manz P, Power T, Roggman L, Eisenberg R, Gernhart A, Faison J, Ridgard T, Wallace L, Whitenack J (2017)(11)	To assess the content fidelity approach of the curriculum of the program in home visit.	A quantitative study by self-applied measuring tool by visitors.	Visitors (n= 08)	United States
Schodt S, Parr J, Araujo M, Rubio-Codina M (2015)(13)	To review the literature on the definition and quality measurement of home visiting programs to promote early childhood development	A literature review that describes measurement tools to be used in the assessment of home visit.	Visiting programs	United States
King P (2016)(29)	To develop a structured and oriented tool for assessment and recording of home visit content.	A methodological study	Visiting programs	United States
Tomlin A, Hines E, Sturm I (2016)(30)	To assess home visit through the interaction of visitor with participant.	A qualitative study through an interview with the visitors.	Visitors (n= 09)	United States

Home visit assessment strategies

In relation to home visit assessment strategies in visiting programs, publications were categorized into three assessment modalities, based on the study objectives. Chart 3 presents the assessment strategies adopted and the visiting programs.

Chart 3
Modalities of assessment of home visit and visiting programs

Assessment Modality	Visiting Program
Analysis of Visiting Notebooks	Pro-Kind(27)
	Parent Support Program(25)
	CAPEDP Project(13)
Interview	Every Child Succeeds(21,22)
	Maternal, Infant, and Early Childhood Home Visiting(20)
	Indiana First Steps(30)
Tools	Cuna Más in Peru(16)
	Creciendo con Nuestros Hijos(16)
	Programa de Acompañamiento a la Política de Primera Infancia(16)
	Programa Primeira Infância Melhor(16)
	Home Visits Program in Kingston and Saint Andrews(16)
	Atención Integral de la Niñez con Participación Comunitaria(16)
	Consejo de Salud Rural Andino (CSRA) (16)
	Partnering with Families for Early Learning(19)
	Nurse-Family Partnership(10)
	Family Nurse Partnership(24)
	Early Head Start(9,11,28)
	Early Childhood Block Grant(26)
	Parent as teacher(30)

Visiting notebooks analysis

This thematic category was the least prevalent in terms of frequency, with three occurrences. The notes made by the visitor during home visit were used as a source of information referring mainly to the content addressed in the visit and if such contents were consistent with the curriculum of the programs.

The topics most commonly analyzed in the notebooks are the contents that make up the program curriculum and should be addressed in the visits, for example, in the assessment of a program by analyzing 1,058 notes of home visit books of 105 families.²³ This study demonstrated that some topics relevant to the program were not addressed or were partially addressed during the visit, such as: health education, child development, family environment, mother’s education plans and personal routine, partner support and play with kid. Some themes that were not part of the scope of the program emerged during home visit, such as social problems, family relationships and health services.²³

An analysis of the content addressed over time revealed that health issues and skills development remained stable in both initial and late visits. However, activities addressing early childhood development decreased from 28% during the initial visits to 16% at subsequent visits. In addition to a high percentage of subjects that did not fit the pre-established taxonomy for intervention assessment.²⁵

Another way to analyze notebooks is to estimate the time spent in each domain to be addressed during the visit. This allows to verify if the domains are being worked in the predicted moment and if there is continuity in the conduction of the subject, besides checking if the educative materials are being used with the family.²⁷

Interview

Three studies made up this category. Involving participation of the family and the visitor in the assessment, from a qualitative perspective, allows access experiences and feelings of individuals involved in the intervention. This methodology allowed mothers participating in a visiting program to express feelings and make an individualized assessment of the interventions.²²Regarding visitor interview, studies were directed to implement or to improve strategies of reflexive practices of family interaction. The objective was to verify if the practices adopted at home, starting from a hypothetical situation at the time of supervision, were in line with the one recommended in the program guidelines. The situation was presented and the visitor was questioned with the following question: “If you observed this interaction between parents and children, what would you say or do next?”³⁰This approach, besides assessing home visit, also serves as a possibility for the professional development of the visitor. Both visitors and supervisors were questioned about how reflective practice impacted the conduct of work, the sense of effectiveness, the management of difficulties encountered in living with families and stressful aspects of work.²⁰

Tools

This category was the most prevalent in terms of frequency. The data are collected through the observation of the visit, either self-employed (own visitor) or an external observer. It is commonly adopted the filming or audio recording of some visits throughout the duration of the program, so that they have an assessment of diverse moments.⁹ Tools focus on domains related to dosage, content and relationship, provide quantitative data and culminate in a score of points that qualifies home visit.¹⁷Chart 4 describes the domains assessed in each tool.

Chart 4
Description of tools and their domains assessed

Tool	Domains assessed
Working Alliance Inventory	Visitor-participant involvement
Home Visit Rating Scale	Responsibility of the visitor to the family;
	Relationship with family members;
	Facilitating the interaction between caregiver and child;
	Non-intrusion and collaboration of the visitor;
	Caregiver-child interaction;
	Involvement of the caregiver and the child in the visit.
Home Visiting Encounter Form	Time to approach the program content.
Home Visit Characteristics and Content form	Duration of visit
	Participants of the visit;
	Developed activities;
	Time in each activity;
	Distractions during the visit.
Home Visit Observation form	Interviewer-caregiver-child interaction;
	Engagement of the family;
	Content of the visit.
Home Visit Assessment Tool	Content addressed at home visit;
	Engagement of participants;
	Description of the visit and resumption of the last visit.
COACH (Competent Adherence to the Family Check-Up)	Content addressed at home visit;
	Responsive relationship between visitor and participant.
Nursing Practice Assessment	Content addressed at home visit;
	Collaborative practice and therapeutic relationships;
	Organization and documentation of the visit.
Home Visiting Program Quality Rating Tool (HVPQRT)	Content addressed at home visit.
Home Visit Checklist	Description of the visit and resumption of the last visit;
	Activities and methods used;
	Caregiver-visitor-child relationship;
Little Talks Fidelity form	Content and materials used in home visit;
	Engagement of participants.

Discussion

Mapping the literature on home visit assessment strategies in early childhood visiting programs allowed the identification of several modalities adopted by the programs and each one serves a different purpose. The choice of the most appropriate means to assess home visit in visiting programs depends on factors related to the financial availability, personnel, time, expertise and adequacy to the proposed objectives.¹⁶There is no agreement on the most appropriate and effective methodology, because the intervention scenarios and the objectives of the programs are very varied around the world. The results demonstrated that there is a greater quantitative of the use of tools, to the detriment of the documentary analysis and qualitative aspects of the intervention.

Home visit assessment in visiting programs is based mainly on three essential elements - dosage, content and relationship. Dosage consists of the frequency of visits, duration of the program and the average time of each home visit. Content refers to program curriculum and guidelines that were designed according to the objectives that are to be achieved.¹⁷ Moreover, the relationship is the central element in home visit, since the basis of the intervention is based on participant mutual trust and engagement.¹¹

A systematic review of the quality criteria adopted in 20 home visiting programs showed that all initiatives had minimum requirements for visits and prior training of visitors. Most of the interventions were associated with Brazilian programs or higher education institutions that offered training and support, and had protocols to monitor the fidelity of visits in relation to the content addressed and activities developed.³

A study that explored home visiting practices in relation to child development showed that when the visitor used good home visiting practices, the family and child were more effectively involved in the activities. Parental results were stronger and, in turn, the child’s developmental outcomes were better. Home visits quality was reflected in the positive relationships of visitors with families, family responsiveness, facilitation of positive mother-child interactions, and collaboration without interference with families, as well as involvement of families in home visits.⁹When there is a relationship of trust between mother and visitor, in addition to achieving better results in child development, there are also positive impacts on family functioning and parenting.³¹

Home visits assessment through notebooks analysis made it possible to visualize the complexity of knowledge and themes that arise during the visit, which demands from program opening formulators for visitor flexibility and autonomy to suit the family needs. Thus, it makes it possible to adapt the curriculum to the reality and the social, psychological and health needs of the target population to ensure that the intervention has an impact on the individual and the community.¹¹Tool use makes it possible to assess home visits by numerical and comparable parameters, being a very useful tool when it is intended to give a program scalability.⁴

When assessing home visit, the visitor’s ability to work with the family is monitored the proposed curriculum of the program.¹⁷ However, visits being the delivery tool of the intervention in early childhood, composes a broader structure that involves supervision, training, availability of resources that also need to be analyzed when thinking about strategies to improve home visits.²⁶ The study’s limitation was the difficulty demonstrating which assessment methodology had the best results in practice. Challenges for future research are to develop studies that demonstrate the effectiveness of evaluative interventions, as well as to propose validated tools and methods.

Conclusion

The present scope review has shown that home visit assessment in early childhood visiting programs has been better explored in recent years, mainly due to the expansion of programs. It is worth noting the scarcity of assessment processes in poor and developing countries. The present review highlights a gap in home visit assessment strategies and instrumentalizes programs to include this approach in the monitoring of interventions according to the objective of each program and availability of resources.

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Publication Dates

• Publication in this collection
  10 Oct 2019
• Date of issue
  Sep-Oct 2019

History

• Received
  6 Aug 2018
• Accepted
  14 June 2019