Public Health Nursing Vol. 21 No. 3, pp.
207–219
0737-1209/04/
# Blackwell Publishing, Inc.
Nurse Home Visits to Maternal–Child
Clients: A Review of Intervention
Research
Diane B. McNaughton, Ph.D., R.N.
Abstract Home visiting has been considered a promising strategy
for addressing the multiple needs of families at risk. Research
reviews are a valuable resource for researchers, policymakers,
and practitioners who develop and support new home-visiting
interventions. This review examines 13 research studies published
between the years of 1980 and 2000 that test the effectiveness of
home-visiting interventions using professional nurses as home
visitors. Findings indicate that a wide range of client problems
are addressed during home visits using a variety of nursing
interventions. Missing from most of the reports is a clear theo-
retical link between the client problem addressed, the nursing
intervention, and target outcomes. About half of the studies
were successful in achieving desired outcomes. Future research
should be directed by middle-range practice theory, clearly
explicate the nursing intervention being tested, use power analysis
to determine sample size, and report reliability and validity of
dependent variable measures with culturally diverse samples.
Key words: home visiting, research review, public health nursing.
Diane B. McNaughton is Assistant Professor, Community and Mental
Health Nursing, Rush University, Chicago, Illinois.
Address correspondence to Diane B. McNaughton, Rush University
College of Nursing, 600 S. Paulina Street, Suite 1030a, Chicago, IL
60612. E-mail: diane_b_mcnaughton@rush.edu
In recent years, there has been growing interest in
developing, implementing, and evaluating home-visiting
programs to maternal–child clients. Researchers have
demonstrated that a wide range of health and social
problems can be addressed with home-visiting interven-
tions. Some of these interventions have produced
impressive findings (Olds, Henderson, Tatelbaum &
Chamberlin, 1986, 1988; Norbeck, DeJoseph, & Smith,
1996; Kitzman et al., 1997) and have inspired others to
develop new programs. Those who develop new home-
visiting programs can benefit from examining previous
studies to determine the types of problems that are
amenable to home-visiting interventions as well as to
gain insight into successful home-visiting strategies.
Although several reviews of home-visiting research
have been published (Combs-Orme, Reis, & Ward, 1985;
Olds & Kitzman, 1993; Kearney, York, & Deatrick, 2000),
they often fail to address essential information needed to
guide future home-visiting programs and research. Ques-
tions that have not been adequately addressed in previous
reviews are: Which client problems are amenable to change
via home visits provided by a nurse? Which theories have
researchers identified as useful in guiding interventions
for particular client problems? What is the minimum dose
of home visits needed to influence the desired outcome?
Which outcome measures are sensitive to home-visiting
interventions? In fact, previous reviews offer little
guidance in distinguishing theories that are useful and char-
acteristics of interventions that are effective in achieving
their goals. In addition, a limitation of most reviews of
home-visiting research is that they aggregate studies that
include home visitors of various skill and education and do
not specifically examine the effectiveness of nursing inter-
ventions. Therefore, the purpose of this review is to address
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these concerns through a critical analysis of home-visiting
research and to provide practical recommendations to
guide future clinical trials of home-visiting interventions
as well as to inform public policy and nursing practice.
Although several types of home-visiting research exist
(qualitative studies, evaluation research, and experimental
and quasi-experimental studies), this review will only
include experimental studies using registered nurses as
home visitors. Other research was excluded from the review
because criteria for evaluating the various types of studies
differ. In addition, some of the research has been reviewed
elsewhere. For example, McNaughton (2000) reported a
synthesis of qualitative studies describing nurses’ experi-
ences as home visitors and illustrated the process of
home visiting as occurring in phases in which the nurse–
client relationship forms the context for home visiting.
McNaughton noted a gap in the research as a failure of
investigators to examine client’s perspectives of home vis-
iting. Byrd (1995) reviewed past and current literature to
form a concept analysis of home visiting and described the
process of home visiting from contemporary literature as
moving through phases of contacting, entry, and termina-
tion. Throughout the home-visiting process, nurse–client
interaction is described by Byrd to be a crucial component
of home visiting and an influence on client outcomes. Byrd
also reported that in current literature, home visiting is
considered an intervention (or treatment modality) rather
than a context for specific nursing interventions. Byrd’s
report differs from McNaughton’s, in that McNaughton
identified 26 nursing interventions offered during home
visits. Differences between these reports illustrate the
ambiguity that exists about the nature of home visiting.
METHODS
Procedures
Research reports were identified for the review using
computer searches and manual reviews of reference lists
of related articles. Computer searches were conducted on
Medline, Cumulative Index to Nursing and Allied Health
Literature and PsychInfo using and merging the search
words ‘‘home visiting’’, ‘‘maternal–child,’’ and ‘‘public
health nursing practice’’. Criteria for selecting articles to
be reviewed included: (a) research testing the effectiveness
of home-visiting interventions by registered nurses, (b)
independent variable designed by a researcher (rather
than evaluation of existing public health-nursing services),
(c) nursing interventions directed toward pregnant women
or mothers with young children, (d) use of experimental
design to evaluate the effectiveness of the nursing inter-
vention, and (e) research published between 1980 and 2000.
Review of Research Reports
The research reports were reviewed for: author and date,
purpose of the study, client problem addressed in the
research, characteristics of study participants, theoretical
framework, nursing intervention, evaluation measures,
and treatment effects.
RESULTS
Fifteen research reports were retrieved that met the cri-
teria for the review. Two of the studies were eliminated
because findings were primarily descriptive and signifi-
cance tests for differences between treatment and control
groups were not reported (Oakley, Rajan, & Grant, 1990;
Starn, 1992). The final 13 reports included in the review
are presented in Table 1. The reports represent research
that took place in three countries: United States (n=10),
Australia (n=2), and Taiwan (n=1).
Client (Population) Problem
Client problems addressed by home-visiting interventions
were specified in each of the research reports. Most com-
mon (n=6) were unfavorable birth outcomes, such as
infant mortality, prematurity, and low birthweight (Olds
et al., 1986; Bryce, Stanley, & Garner, 1991; Barnes-Boyd,
1995; Norbeck et al., 1996; Kitzman et al., 1997; Koniak-
Griffin, Anderson, Verzemnicks, & Brecht, 2000). Other
problems included psychosocial risks (such as unemploy-
ment, adolescent parenthood, single parenthood, history
of family abuse, and others) that were considered to be
mediating variables and could ultimately affect the health,
growth, and development of infants (Black, Nair, Kight,
Wachtel, Roby, & Schuler, 1994; Booth, Mitchell, Barnard,
& Spieker, 1989; Cappleman, Thompson, DeRemer-Sullivan,
King, & Sturm, 1982). The remaining problems were
related to encouraging breast-feeding promotion (Chen,
1993) and maternal–child bonding (Hall, 1980).
Population Characteristics
Participants in a majority of the studies were either preg-
nant or postpartum and had multiple risk factors such as
teen parenthood, single parenting, low income, lacking
social support, drug or alcohol abuse, smokers, and being
at risk for delivering a low-birthweight baby. Exceptions
were Braveman, Miller, Egerter, Bennett, English, Katz,
and Showstack (1996) and Hall (1980) who examined the
effects of a single postpartum home visit to families who
were not targeted because of specific risk factors.
Research participants were primarily African American
TABLE 1. Home-Visiting Research

Reference and Problem

theory addressed Sample Intervention Outcome measures Findings
Koniak-Griffin Adolescent Pregnant teenagers, 5 HV; L=2–2.5 h. Nursing Child Assessment +educational outcomes
et al. (2000). pregnancy places Latina, White, and Dose: 10–12.5 h. Focus: Teaching Scale (NCATS), for mother‡;
Theory: Implicit*; mothers at risk Black. Low SES, various interventions, R+, V+ Social –use of prenatal health
Rating†: 0 for social and single, mostly counseling, health competence composite, care§;
economic primips, high information, problem R–, V+ Medical Records –infant birth weight;
problems. school students or solving, referrals –use of alcohol, smoking,
drop outs. Some marijuana;
employed. n=121 –NCATS (parent–child
interaction);
–social competence
Armstrong Maternal risk Australian Weekly HV pos partum Edinburgh Post Natal +postnatal depression
et al. (1999). factors place postpartum for 6 weeks. L=not Depression Scale, R–, V+; (primips),
Theory: children at risk women at risk. stated. Dose: not stated. Parenting Stress Index, +parental stress;
Implicit. for poor health. n=181 Focus: develop relationship R–, V–; Home Observation +home environment;
Rating: 0 of trust with family, for Measurement of the –breastfeeding rates;
enhance parenting self–esteem, Environment (HOME), –use of health services
anticipatory guidance, promote R+, V+; Patient
preventive child health care, Satisfaction, R+, V–
referral.
Kitzman et al. Poor pregnancy Primiparous Ave 33 HV during pregnancy Medical Records. HOME, +use of health services;
(1997). Theory: outcomes, child pregnant women, and postpartum. L=not R–, V–. NCATS, R–, V–. +fewer pregnancy induced
Human ecology, abuse, and neglect two risk factors: stated. Dose: not stated. Bayley Scales of Infant hypertension;
self–efficacy, unmarried, HV focus: health behavior Development, R–, V– +fewer yeast infections;
human attachment. <12–year assessment, health teaching, +children: fewer
Rating: 1 education, or infant care, parent–child ingestions & injuries;
unemployed. interaction, child development, +HOME;
n=1139 problem solving +fewer subsequent
pregnancies;
–birth outcomes;
–use of prenatal care;
–NCATS; – Bayley/infant
development;
–mother’s education;
–mother’s employment
Braveman et al. Safety of early Ethnically diverse 1 HV 2nd to 3rd day Medical Records +fewer acute care
(1996). Theory: hospital discharge newborns and postpartum; Nurse office visits;
None. Rating: 0 with HV not low–risk mothers. available by telephone; –hospitalizations;
established n=174 L=not stated; Dose: –well-baby visit
not stated; Focus:
assessment, education,
consulting MD,
McNaughton: Home-Visiting Research

breastfeeding promotion
209
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TABLE 1. Continued

Reference and Problem

theory addressed Sample Intervention Outcome measures Findings

Norbeck, Low Birth Pregnant, 4 HV prenatally Medical Records +higher birth

DeJoseph & Weight African L=not stated weight
Smith, 1996 American, age Dose: not stated
Public Health Nursing

Theory: Implicit 18–34, Medicaid Focus: mobilizing client’s

Rating: 0 eligible, single, social support, provision
unemployed. of social support
N=114
Barnes–Boyd (1995). Infant mortality African American, 4 HV over 8 months. Medical Records +less infant skin problems;
Theory: Interaction inner city with L=not stated. Dose: +less infant respiratory
Model of Client high incidence of not stated. Focus: Health problems;
Health Behavior. low birthweight screening, health services, –infant development;
Rating: 1 births; n=145 instruction –well-baby visits
Black et al. Drug use by Pregnant women HV every 2 weeks for Child Abuse Potential +potential for child abuse;
(1994). Theory: women of child using cocaine or 18 month. L=1 h; Inventory (CAPI), R+, +emotional responsiveness
Ecological bearing age heroin. Single, Dose =36 h; Based on V+; Parenting Stress of mother;
model. Rating: 1 causes neuro– African American, Carolina Preschool Index, R+, V+; Bayley –use of drugs;
developmental low income, inner Curriculum, Hawaii early Scales of Infant Development, –use of well child health
problems in city, multiparous; learning program. Addressed R–, V–; HOME, R–, V– care;
Volume 21 Number 3 May/June 2004

children n=70 mothers’ concerns. –home environment

Chen (1993). Low incidence Taiwan, healthy 4 HV postpartum; Perceived Stress Scale, –duration of breastfeeding
Theory Orem: of breast newborns. L=not stated; Dose: R+, V+; Breastfeeding
Self Care. feeding n=180 not stated; Focus: Experience Scale, R +, V +;
Rating: 2 Anticipatory guidance, Breastfeeding Attitude
helping mothers Scale, R+, V+
develop coping mechanisms
Bryce et al. Preterm birth Pregnant women HV every 4–6 weeks by Medical Records –preterm birth
(1991). with previous nurse midwife. Number
Theory: Implicit. history of preterm of HV not stated; L=not
Rating: 0 birth, miscarriage, stated; Dose: not stated.
low–birthweight Focus: Expressive support
baby, previous without health information.
perinatal death,
antepartal bleeding;
n=1970
Booth, Mitchell, Not well Socially at risk Ave of 16 HV over Community Life Skills Scale, –social skills;
Barnard & defined. pregnant women. 18 month (prenatal to R+, V–; Adult Conversational –mother
Spieker (1989). n=147 1 year postpartum). Skills Scale, R+,V–; Life –child interaction
Theory: Implicit. L=approximately. 1 h. ExperiencesSurvey, R–, V–;
Rating: 0 Dose=18.5 h (±11.6 h). Difficult Life Circumstances
Compared two types of Scale, R–, V–; Personal Resources
treatment: Information Questionnaire, R+, V–; Beck
model and Mental health Depression Inventory, R+, V–;
model. NCATS, R+, V–; Nursing
Child Assessment Feeding
Scale, R+, V–
Olds et al. (1986). Low birthweight Primiparous, Ave of 41 HV from Medical Records; +aware of community
Theory: Implicit. caucasian, pregnancy to 24 month Diet History services, attended
Rating: 0 low–income, postpartum. L = not stated; childbirth education
teenagers; Dose: not stated; Focus: classes, WIC;
n = 400 Education, enhancing +fewer kidney
support, linking to infections;
community resources +improved diet;
–birthweight, length of
gestation
Cappleman et al. Poor birth outcomes African 1 HV per month for 2 years; Denver Developmental +developmental risk at
(1982). Theory: (low birthweight, American, L = not stated; Dose: not Screening Test, R–, V–; 30 months;
Implicit. Rating: 0 mortality, unmarried, less stated; Focus: parent Bayley Scales of Infant –Child development
prematurity) than 18y, low child relationship, child Development, R–, V–; and IQ
for adolescents SES; n = 37 development Stanford–Binet
Intelligence Test, R–, V–
Hall (1980). Mother’s perceptions Married, aged 1 HV 2–4 days post discharge Neonatal Perception +mother’s perceptions
Theory: Maternal– of infant and 18–30, full term from hospital; L = not stated; Inventories I and II, of their infants
infant bonding. maternal–infant baby; n = 30 Dose: not stated; Focus: R+, V+
Rating: 2 bonding. teaching normal infant
behavior

Note: HV, home visit; L, length of home visit; R, reliability: + reported by author, – not reported by author; V, validity: + reported by author, – not reported by
author; SES, socioeconomic status.
*Implicit frameworks refer to author’s identification of concepts important to the research rather than use of an established (published) theoretical framework.
†Refers to Fawcett’s (1999) rating of use of theory in research.
‡‘+’ refers to a statistically significant (p=0.05) treatment effect.
§‘–’refers to a lack of treatment effect.
McNaughton: Home-Visiting Research
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(Cappleman et al., 1982; Black et al., 1994; Barnes-Boyd,
1995; Norbeck et al., 1996; Kitzman et al., 1997) or
Caucasian (Booth et al., 1989; Olds et al., 1986; Bryce
et al., 1991). Racially mixed samples (European American,
Asian American African American, and Latina) were
used in two studies (Braveman et al., 1996; Koniak-
Griffin et al., 2000). Two researchers did not report the
racial characteristics of research participants (Hall, 1980;
Armstrong, Fraser, Dadds, & Morris, 1999).
Sample sizes ranged from 30 to 1970 (mean 362,
median 147). Use of power analysis to determine sample
size needed to measure the effectiveness of the interven-
tion was documented in three reports (Armstrong et al.,
1999; Norbeck et al., 1996; Kitzman et al., 1997). Small
sample sizes (75 or less) that would limit the detection of
small or medium treatment effects were used in three
studies (Black et al., 1994; Hall, 1980; Cappleman et al.,
1982). All researchers used convenience samples and most
randomized participants to treatment and control groups.
Refusal rates for persons declining participation in the
research protocols were reported in five studies and ran-
ged from 9 to 54% (mean 21%, median 12%). Lower
refusal rates were reported in studies where women had
inadequate social support (Norbeck et al., 1996) or were
substance abusers (Black et al., 1994), suggesting that
persons with greater needs may be more interested in
participating in research interventions. Higher refusal
rates (54%) were reported by Armstrong et al. (1999) in
a study in which women were invited to enroll in a home-
visiting program during their postpartum hospitalization.
Explanations for high refusal rates were not provided by
the authors; however, it may be possible that new
mothers may not feel the need for support in the immedi-
ate postpartum period when support from health care
providers is available. The authors did note that women
with a history of psychiatric illness or family financial
stress were more likely to consent to participate, again
suggesting that persons with greater needs may be more
likely to consent to home visits.
Drop-out rates were reported in 11 studies and ranged
from 2 to 35%. Of the two studies (Bryce et al., 1991;
Armstrong et al., 1999) with very low drop-out rates
(2 and 2.7%, respectively), one study provided home visits
to women during pregnancy who had history of preterm
birth, birth to a low-birthweight baby, miscarriage,
antepartal bleeding, or perinatal death (Bryce et al.). The
second study (Armstrong et al., 1999) provided home
visits to women whose newborns were at risk for poor
health or developmental outcomes as a result of maternal
psychosocial risk, such as partner abuse, young maternal
age, financial stress, social isolation, unstable housing,
and drug and alcohol abuse. Because these two studies
included participants at risk for poor pregnancy out-
comes or poor health for their infants, women may have
been motivated to remain in the study because of its
possible benefits. In addition, the intervention was rela-
tively short (during pregnancy or during the first 6 weeks
postpartum) and did not require a long-term commitment
from participants.
Highest drop-out rates were reported for studies in
which home visits lasted for 18 months (Booth et al.,
1989; Black et al., 1994). The drop-out rate reported by
Black and colleagues was 28%; however, the sample
consisted of women who were substance abusers during
pregnancy, and participants were lost to factors such as
incarceration, change of health care provider, and
noncompliance with the research protocol. Thirty-five
percent of participants dropped out of the study by
Booth et al. for reasons such as relocation to another
area, refusal to participate, and infant factors such as
abortion, miscarriage, adoption, or death. The high
drop-out rates of these studies illustrate the difficulties
involved in retaining research participants in studies over
time, especially when they are considered at high social
risk. It is interesting to note that two clinical trials con-
ducted by the David Olds team have followed partici-
pants over time and report relatively low drop-out rates
of 19% at 15-year follow-up for the original Elmira study
(Olds et al., 1997) and 9% at 54 months for the Memphis
study (Kitzman et al., 1997).
Characteristics of communities in which home-visiting
interventions were implemented were not described in
much detail. Most studies took place in urban areas and
in communities served by large medical centers or teach-
ing hospitals (Hall, 1980; Cappleman et al., 1982; Bryce
et al., 1991; Chen, 1993; Barnes-Boyd, 1995; Braveman
et al., 1996; Norbeck et al., 1996; Kitzman et al., 1997;
Koniak-Griffin et al., 2000). Cultural characteristics of
research participants that may influence health behavior,
preferences for delivery of health care, and use of health
services were not described. An exception was the prelim-
inary work reported by Norbeck, DeJoseph, and Smith
(1996) in which focus groups were held with African
American women to determine the characteristics of
social support that they needed during pregnancy. This
preliminary work provided the basis for the focus and
content of the home-visiting intervention that followed it.
Theoretical Frameworks
Use of theoretical frameworks was rated using a frame-
work reported by Fawcett (1999) (ratings assigned to
each study are indicated on Table 1). Fawcett identified

four ratings for evaluating a researcher’s use of theory in
research reports. Following is a description of the ratings:
0 A rating of ‘‘0’’ is given to a study in which a
theoretical framework is not identified.
1 A rating of ‘‘1’’ indicates insufficient use of the
framework and is applied when the conceptual
model is named and briefly summarized.
2 Minimal use of a conceptual model is given a rating
of ‘‘2’’ and refers to studies in which a model is
named and briefly summarized. The linkage between
the conceptual model concepts and propositions
with the middle-range theory concepts and propos-
itions and the empiric research methods is evident.
3 Finally, adequate use of a conceptual model is given
a rating of ‘‘3’’. For studies receiving this rating, the
conceptual model is named and summarized clearly
and concisely. The linkage of the conceptual model
concepts and propositions with the middle-range
theory concepts and propositions and the empiric
research methods is clearly stated.
In addition, for this review, conceptual frameworks
were either identified as implicit or explicit. Implicit frame-
works were identified as those that were not named but
could be derived from the study by identification of the
concepts the researcher is studying and their relationships
(Polit & Hungler, 1999). Implicit frameworks were given
a rating of ‘‘0’’ using Fawcett’s (1999) criteria. Explicit
theories are those that are identified by name along with a
reference citation.
Explicit theories were identified by five researchers.
None of the studies were given a rating of ‘‘3’’ using
Fawcett’s criteria. Two studies (Hall, 1980; Chen, 1993)
described the theory and explained how the theory direc-
ted the home-visiting intervention and were given a rating
of ‘‘2’’. Three studies (Barnes-Boyd, 1995; Black et al.,
1994; Kitzman et al., 1997) were given a rating of ‘‘1’’
because they named theoretical frameworks but did not
provide a description of the theories and their contribu-
tion to guiding the intervention and selection of depend-
ent variables.
Implicit frameworks were used by eight researchers
who identified the primary concepts of interest to their
studies. Concepts identified most often represented client
problems such as a need for social support (Bryce, 1991;
Norbeck et al., 1996), interpersonal competence (Booth
et al., 1989), client vulnerability and maternal competence
(Koniak-Griffin et al., 2000), parenting risk (Cappleman
et al., 1982), psychosocial risk and poor parenting
(Armstrong et al., 1999), and problems of low birthweight
related to maternal health habits (Olds et al., 1986). Only
one study (Braveman et al., 1996) did not identify con-
McNaughton: Home-Visiting Research 213
cepts of interest. Researchers who did identify concepts
focused on those that described or explained client
problems but did not present a theoretical link between
client problems, specific nursing interventions, and out-
comes. In this body of research, much more attention has
been given to explaining client problems than describing
the details of nursing interventions needed to address
problems.
In summary, the application of theory to home-visiting
investigations is not consistent across studies. The use of
explicitly stated theoretical frameworks to guide identifi-
cation of client problems, selection of nursing interven-
tion and dosage, and the expected changes as a result of
the intervention is not evident in this body of research.
Interventions Delivered in Home Visits
The number of home visits provided to clients varied
greatly between the studies and ranged from one (Hall,
1980; Braveman et al., 1996) to 71 (Kitzman et al., 1997)
with an average of 14.6 (median six). Frequency of home
visits ranged from weekly to every 2 months with an
average of one home visit every 4 weeks. Most protocols
were designed to provide home visits at equal intervals.
Exceptions were Booth et al. (1989) and who allowed the
visiting nurse and client to determine the frequency and
duration of contacts. Olds et al. (1986) tapered home
visits from weekly after a baby’s birth to every 6 weeks
when the child was 18–24 months of age.
Rationale for the number of visits provided was
explained by six researchers. Norbeck et al. (1996)
explained that frequent contact was needed to avoid
loosing research participants. Multiple risk factors experi-
enced by mothers provided the rationale for the long-
term interventions specified by Olds et al. (1986) (mean
41 home visits per client) and Black et al. (1994) (mean
36 home visits per client). Koniak-Griffin et al. (2000)
explained that the amount of nursing contact given to
each family was based on recommendations published by
Heinicke, Beckwith, and Thompson (1988) regarding the
length and intensity of interventions needed for a positive
effect on maternal–child outcomes in high-risk families.
Cappleman et al. (1982) provided 24 home visits as speci-
fied in the Carolina Infant Curriculum. The remaining
researchers did not provide rationale for the number of
home visits provided.
The length of home visits was reported by Black et al.
(1994) and Booth et al. (1989) who provided home visits
that lasted about 1 h and Koniak-Griffin et al. (2000) who
provided home visits lasting 2–2.5 h. Other researchers
(n=10) did not state the length of time spent during
home visits. The total ‘‘dose’’ of nursing contact can be
214 Public Health Nursing Volume 21 Number 3 May/June 2004
determined by multiplying the number of visits by the
length of visits. Booth et al. (1989) reported the average
total dosage of nursing contact received per research
participant to be 18.5 h. The total dosage for participants
in the Black et al. study was 36 h, and mothers in the
preliminary findings reported by Koniak-Griffin et al.
received 10–12.5 h of contact.
Content of interventions during home visits was
described in all but one report. Seven of the studies
reported that developing nurse–client relationships was
a specific focus of the intervention (Olds et al., 1986;
Booth et al., 1989; Bryce et al., 1991; Black et al., 1994;
Barnes-Boyd, 1995; Norbeck et al., 1996; Kitzman et al.,
1997). Home visits that were individualized to the client’s
concerns and provided consistent contact between one
nurse and a client were the focus of two protocols (Kitzman
et al., 1997; Olds et al., 1986). Although nurse–client
relationships were considered important to home visiting,
researchers did not specify steps needed to foster relation-
ship development, length of time needed to develop
the relationship, and indicators that a relationship
was ‘‘developing’’. In addition, nurse–client relationship
theories were not used to guide any of the studies, and
research findings were not discussed in relation to these
theories.
Two studies provided only social support (Bryce et al.,
1991; Norbeck et al., 1996). However, social support was
delivered differently across the studies. In a study by
Bryce et al. (1991), social support was provided by sup-
plying expressive and instrumental aid as described by
Thoits (1982). The authors described expressive aid as
including provision of sympathy, empathy, understanding,
affection, acceptance, and being a confidante. Instrumental
support included providing information, advice, and
material aid. Efforts to determine nursing behavior that
would communicate expressive and instrumental support
to mothers was not discussed by the researchers. In
another study, Norbeck et al. provided a social support
intervention to African American mothers at risk for
delivering a low-birthweight baby. Norbeck and col-
leagues conducted preliminary work to determine cultur-
ally meaningful methods of social support for mothers
and designed the intervention to provide the desired sup-
port. In Norbeck’s study, social support was provided by
supplying emotional support and helping women mobil-
ize their own social support.
Two researchers (Hall, 1980; Braveman et al., 1996)
measured the effects of one home visit for well families
in the early postpartum period. Hall (1980) provided one
home visit to new mothers that focused on providing
information regarding normal infant behavior. Braveman
et al. (1996) conducted a retrospective chart review to
determine the effects of a single postpartum home visit
on use of acute care services. Focus of the intervention
provided by Braveman and colleagues included assess-
ment, health education, and making referrals. Both of
the studies were successful in achieving their goals. Effects
of Hall’s single home visit were measured 1 month after
the intervention, noting that mothers who received home
visits had more positive perceptions of their infants than
women who did not receive the home visit. Braveman
et al. determined that infants whose mothers received a
home visit were less likely to use acute care services during
the infants’ first 2 weeks of life.
The remaining reports described multifaceted interven-
tions that included assessment, provision of health infor-
mation, support, referral, coordination of other related
health services, modeling of healthy interaction with
infants, and health screening (Armstrong et al., 1999;
Cappleman et al., 1982; Chen, 1993; Koniak-Griffin
et al., 2000). Overall, 19 different nursing activities were
reported (Table 2).
Preparation of the home visitor and assurance of pro-
fessional competency was reported in eight of the studies.
However, discussion regarding preparation of nurses as
home visitors focused primarily on educating the nurses
to implement the intervention as it was designed rather
than specifying formal educational preparation. Two
researchers indicated the educational preparation of
nurses. Koniak-Griffin et al. (2000) employed nurses
with BSN degrees and certification in public health
nursing. Bryce et al. (1991) used nurse midwives as
home visitors but did not indicate if they held certificates
in midwifery or were prepared at the graduate level. One
researcher (Black et al., 1994) explained that a ‘‘profes-
sional’’ was needed to address the multiple needs of
women in the study but did not indicate the type or
level of professional preparation needed. Although client
risk factors were often complex, researchers did not dis-
cuss the minimal educational competency needed by
home visitors to competently address difficult issues.
Outcome Measures
Selection of outcome measures varied between reports
and reliability and validity of measures were reported
inconsistently (Table 1). Instruments measuring statistic-
ally significant differences between treatment and con-
trol groups were: The Edinburgh Post Natal Depression
Scale and the Parenting Stress Index (Armstrong et al.,
1999), Home Observation for Measurement of the Envir-
onment (HOME) (Olds et al., 1986; Black et al., 1994;
Kitzman et al., 1997; Armstrong et al., 1999), Nursing
Child Assessment Teaching Scale (NCATS) (Kitzman
 McNaughton: Home-Visiting Research 215

TABLE 2. Home Visiting Interventions (1994) reported acceptable reliability scores for the Child
Abuse Potential Inventory and the Parenting Stress Index
Anticipatory guidance1,9
Assessment5,10
from data obtained in her study with a low-income Afri-
Breastfeeding promotion8,12 can American sample; however, reliability of the HOME
Counseling11 scale for her population was not reported.
Developing nurse-client relationship3,4,6,10,12,13
Encouraging use of child preventive health services1
Treatment Effects
Enhancing parental self-esteem1
Establishing trust1 A range of positive treatment effects were reported across
Focus on mother’s concerns3,6 the studies and included improvement in physical health
Health information2,5,9,10,11 of the mother and child (Olds et al., 1986; Barnes-Boyd,
Health services2 1995; Kitzman et al., 1997; Koniak-Griffin et al., 2000),
Listening6
mental health of the mother, improved parent–child
Mobilizing social support12,13
Parenting4,10
interaction, home environment (Armstrong et al., 1999),
Problem solving10,11 maternal perceptions of infant behavior (Hall, 1980),
Promoting child cognitive development10 fewer incidences of child abuse and childhood injuries
Referral1,11,13 (Olds et al., 1986; Kitzman et al., 1997), maternal life
Screening2 course (Olds et al., 1988), and use of health services
Social support6 (Braveman et al., 1996). Studies that showed differences
1 between treatment and control groups for child develop-
Armstrong, Fraser, Dadds & Morris, 1999.
2 ment and IQ typically were long-term interventions span-
Barnes-Boyd (1995).
3
Black et al. (1994).
ning over at least 2 years and providing at least one home
4
Booth, Mitchell, Barnard & Spieker (1989). visit per month (Cappleman et al., 1982; Olds et al.,
5
Braveman et al. (1996). 1994). Studies that reported differences in physical health
6
Bryce et al. (1991). indicators for pregnant women reported fewer yeast infec-
7
Cappleman et al. (1982). tions, fewer instances of pregnancy-induced hypertension
8
Chen (1993). (Kitzman et al., 1997), and fewer kidney infections (Olds
9
Hall (1980). et al., 1986). Health benefits to children included
10
Kitzman et al. (1997). decreased incidence of infants born with low birthweight
11
Koniak-Griffin, Anderson, Verzemnicks & Brecht 2000. (less than 2500 g) (Norbeck et al., 1996), fewer respiratory
12
Norbeck, DeJoseph & Smith (1996). problems for infants (Barnes-Boyd, 1995), fewer health
13
Olds, Henderson, Tatelbaum & Chamberlin (1986).
care encounters in which ingestions or injuries were
detected (Kitzman et al., 1997), and fewer emergency
room contacts for accidents and poisonings (Olds et al.,
et al., 1997), Stanford-Binet Intelligence Test (Cappleman 1986). A dose–response effect was reported by Black et al.
et al., 1982; Olds, Henderson, & Tatelbaum, 1994), and (1994) who explained that participants who had more
physical health indicators (Olds et al., 1986; Barnes-Boyd, nursing contact were less likely to report ongoing drug
1995; Norbeck et al., 1996; Kitzman et al., 1997). abuse and were more compliant with primary care than
Researchers who used minority samples reported estab- those who had less nursing contact.
lished reliability of instruments with these populations Although many positive effects of home visiting were
inconsistently. For example, Koniak-Griffin et al. (2000) noted, health outcomes varied between studies. In some
reported acceptable Cronbach’s alpha scores for the cases, home visitation improved a client’s use of health
NCATS (0.80 for the total score and 0.77 for the mother’s services (Braveman et al., 1996); in others it did not
score) with a mixed racial sample but did not report (Barnes-Boyd, 1995; Armstrong, 1999). Two studies that
reliability scores for the social competence measures measured child development and cognition as dependent
with minority populations. Kitzman et al. (1997) did not variables found improvement with home visitation
report established reliability or validity for measures used (Cappleman et al., 1982; Olds et al., 1994); others found no
with the urban, African American sample in their study. improvement (Black et al., 1994; Barnes-Boyd, 1995). Simi-
Reliability and validity of the Bayley Mental Develop- larly, there was variation in improvement in low birthweight
mental Index and the Stanford-Binet Intelligence Tests and preterm birth with one study showing treatment effects
were not reported for low-income African Americans in (Norbeck et al., 1996) and others not measuring effects (Olds
the Cappleman et al. (1982) study. Black and colleagues et al., 1986; Bryce et al., 1991; Kitzman et al., 1997).
216 Public Health Nursing Volume 21 Number 3 May/June 2004
Lack of measured treatment effects was reported in
several studies. For example, Chen (1993) found that
home visits by a nurse who provided anticipatory guid-
ance and assistance in helping mothers develop coping
mechanisms for breast-feeding problems did not increase
breast-feeding duration. Bryce et al. (1991) reported no
effects of a social support intervention on preterm birth.
However, the researchers provided social support without
first determining whether the research participants
needed social support. Finally, Booth et al. (1989) found
no differences in the interpersonal competence of mothers
who received home visits.
Measurement of treatment effects was done immedi-
ately after the intervention was completed by most
researchers. Assessment of sustained effects was uncom-
mon; however, it is of interest to researchers, policy-
makers, and clinicians to know the possible sustained
benefits of nursing interventions. Those who measured
sustained benefits were Hall (1980) and Chen (1993)
who assessed treatment effects 1 month after the inter-
vention, Braveman et al. (1996) who measured effects 10
weeks after the intervention, and Cappleman et al. (1982)
who measured effects 6 months postintervention. Studies
by Olds et al. (1997) and Kitzman et al. (2000) have meas-
ured treatment effects 15 (Olds) and 3 (Kitzman) years
after interventions were complete. Significant effects were
reported by Hall on mothers’ perceptions of their infants,
and Braveman and colleagues on parental use of acute
care pediatric services during their infant’s first 14 days of
life. Olds and Kitzman reported sustained results includ-
ing increased spacing between births of subsequent chil-
dren, decreased number of subsequent births, and use of
less government welfare resources. In addition, Olds et al.
(1997) report that mothers who received home visits were
reported less frequently for child abuse, reported fewer
behavioral impairments due to drug and alcohol use, and
had fewer arrests reported by state police than control
mothers at a 15-year postintervention follow-up.
Factors limiting the possible success of a program
included small sample sizes (Black et al., 1994; Koniak-
Griffin et al., 2000) and control groups receiving services
similar to intervention groups (Barnes-Boyd, 1995). Authors
of one study (Booth et al., 1989) compared two similar
treatments and therefore did not assess differences between
groups after the study. Two authors attributed lack of
differences in treatment and control group outcomes as due
to failure of the intervention (Bryce et al., 1991; Chen, 1993).
The study by Black et al. (1994) addressed a challen-
ging public health problem – promoting the health and
pregnancies of drug-abusing pregnant women. Results of
the study approached statistical significance in regard to
improved home environments, participant’s self-report
that they were drug free, and use of well-child health
care. It is possible that a larger sample size would have
produced statistically significant findings because large
treatment effects are needed to detect differences for
dependent variables when treatment and control groups
have smaller sample sizes (Hair, Anderson, Tatham, &
Black, 1995).
Characteristics of the Experimental Design
To conclude this review, it is helpful to review the char-
acteristics of the experimental design and to explore
implications for home-visiting research. The purpose of
experimental research is to provide evidence that
enhances our understanding of the relationships between
phenomenon. For example, in home visiting, we would
like to know the relationship between specific nursing
interventions and client health. Traditionally, true experi-
mental designs have been considered by many to be the
most robust method for testing these relationships. Con-
ducting and reporting research in a manner that follows
standards for experimental studies would enhance the
rigor of research and reliability of findings. For home
visiting, experimental research can enhance our under-
standing of the relationships between client problems,
nursing interventions, and target outcomes.
Experimental studies are distinguished from other
types of research by three characteristics: manipulation,
control, and randomization (Polit & Hungler, 1999).
Manipulation refers to the researcher’s action on the
independent variable introduced in the study. For home-
visiting research, investigators can design interventions
controlling many variables such as education of the
home visitor, number of home visits provided, length of
home visits, content and focus of home visits, interval
between visits, and time span over which home visits
should take place. It is the manipulation of these vari-
ables that ultimately results in a unique intervention
whose effectiveness is tested against those who do not
receive the intervention. Therefore, in reports of research
testing the effects of nursing interventions, it is of para-
mount importance that independent variables are clearly
explained in order for others to understand what is being
tested and to make a decision about the applicability of
the research for informing their work.
The second characteristic of experimental research is
control. Control refers to the researchers’ control in
manipulating the independent variable as well as use of
a control group for comparison of the dependent variable
measures (Polit & Hungler, 1999). The purpose of control
groups is to represent the treatment group in all respects
without receipt of a treatment. Reliable comparisons

between treatment and control groups depend on the
equality of the groups on characteristics likely to influ-
ence the dependent variable. Therefore, it is important for
researchers to explain steps taken to determine the
equivalence of groups.
Lastly, experimental studies use random assignment to
place participants in treatment and control groups. Ran-
dom assignment means that each person enrolled in the
study has an equal opportunity to be placed in either
group. Random assignment is a safeguard against acquir-
ing unequal treatment and control groups and conse-
quently assessment of differences in dependent variables
due to group differences rather than as a result of
treatment. Adherence to the principles of experimental
research design will strengthen the body of home-visiting
research and enhance the applicability of findings
to informing future research, practice, and policy
decisions.
DISCUSSION
This review reported a range of client problems that can
be successfully addressed in the context of home visits.
However, many important issues about the implementa-
tion of home-visiting programs that impact their success
or failure remain unclear. First, use of theoretical frame-
works to guide selection of an appropriate nursing
intervention to address client problems and support a
desired outcome was missing in most of the reports. The
type of theory needed is middle range and should pre-
scribe nursing interventions specific to addressing the
problem of interest and a causal explanation for how
the nursing intervention leads to desired outcomes (Sidani
& Braden, 1998). Future studies should explore the issue
of nursing dosage to determine how much nursing cont-
act and the type of nursing contact is needed to address
specific issues. For example, the nursing dosage and type
of nursing intervention would differ if the goal of the
home visit is to link clients with a free immunization
program versus problem solving in a situation of domes-
tic violence. Without explication of specific interventions,
home visiting remains a ‘‘black box’’ or an unknown
intervention, impossible to replicate and therefore limit-
ing the value of many experimental studies for influencing
public policy and nursing practice.
It is interesting that many of the studies reviewed cited
the importance of the nurse–client relationship to the
delivery of the home-visiting intervention. However,
nurse–client relationship and interaction theories (e.g.,
Peplau, 1991; Cox, 1982) that could be used to monitor
and or direct interventions were not used. Complement-
McNaughton: Home-Visiting Research 217
ing the area of nurse–client interaction and relationship
literature is the body of client–provider interaction
research. This research highlights the complexity of
human interaction and its influences on client appraisal
of health care encounters, client health behavior, and
health outcome (Roter et al., 1995; Stewart, 1995;
Cooper-Patrick et al., 1999; Roter, 2000). A needed area
for future home-visiting research is the exploration of the
processes of nurse–client interaction, how interaction
changes over time, and the amount and intensity of nur-
sing contact (dosage) needed to influence a range of client
problems and outcomes. We also need to illuminate the
association between nurse–client relationship and dosage
issues.
Fawcett (1999) and Chinn & Kramer (1995) explain the
reciprocal relationship between theory, research, and
practice. A primary function of research is to test theories
used to guide interventions. When theories are found to
be useful in directing effective interventions, they can be
used to guide future studies addressing similar problems
as well as to direct nursing practice and guide public
policy. In future studies, a clear linkage between theories
used to guide research design and implementation will
contribute to the building of nursing knowledge in this
area as useful theories are identified.
In much of the home-visiting literature, there is confu-
sion regarding whether home visiting is an intervention
itself or a context for more specific nursing interventions.
The research reviewed here supports the idea that home
visiting is a context, and in fact 19 different interventions
were identified. To clarify this point, a comparison can be
made between ‘‘hospital nursing’’ and ‘‘home visiting nur-
sing.’’ Both are contexts for practice, but the context
alone does not specify the interventions that take place.
Many of the studies reviewed for this article tested the
effects of nursing interventions using small sample sizes.
The use of small sample sizes limits the detection of small
to moderate treatment effects and may actually mask the
true effects of an intervention (Type II error). Future
studies should select sample sizes based on a power ana-
lysis that allows detection of small and medium treatment
effects. Interpretation of research findings would also be
enhanced by use of dependent variable measures that
have been tested for reliability and validity with minority
populations.
CONCLUSION
To improve the rigor of future home-visiting studies,
theories should be used that not only explain client pro-
blems but also provide a framework to link nursing
218 Public Health Nursing Volume 21 Number 3 May/June 2004
interventions to client problems and proposed outcomes.
Nursing interventions should be clearly defined in terms
of content, frequency, length of contacts, and number of
contacts. Nurse–client relationships should be monitored
and measured as they develop and should be explored in
relationship to study outcomes. In order to determine
treatment effects, sample sizes should be based on
power analysis so that interventions with at least medium
treatment effects can be detected. As rigor improves in
home-visiting research, we will gain a better understand-
ing of client problems amenable to home-visiting inter-
ventions as well as specific nursing interventions useful in
improving the health of at-risk populations.
ACKNOWLEDGMENTS
The author acknowledges and thanks Dr Julia Muennich
Cowell and Dr Deborah A. Gross for their helpful critique
of this paper.
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