Abstract
We used data from a home visiting trial to examine low-income women's perceptions of services received from nurses (the community care [CC] group) and from a nurse–community health worker (CHW) team. More mothers in the nurse–CHW group than in the CC group reported receiving help in all of the categories assessed. For both groups, assistance with health education ranked highest among the types of assistance received. A higher percentage of women in the nurse–CHW group than the CC group reported that they received psychosocial help.
Low-income pregnant and postpartum women are disproportionately exposed to stressors that have negative consequences for their mental and physical health and make it difficult for them to participate in programs that could provide help.1,2 Home visits, primarily delivered by nurses3 or community health workers (CHWs),4,5 are a strategy used to provide additional services to low-income women. However, few reported home visiting programs have teamed nurses with CHWs.6,7
We developed a nurse–CHW team intervention in the context of a Medicaid, state-sponsored enhanced prenatal and infant services (EPS) home visiting program in Michigan. Given low enrollment in EPS during pregnancy (only 28% of Medicaid-enrolled women in Michigan participated in EPS), the team intervention was designed to use CHWs to improve engagement, increase service delivery, and address stress and mental health.8 Trained CHWs used empowerment strategies to provide intensive, relationship-based support; deliver health education; and help with service navigation.9
The team model was tested in a trial comparing usual community care (CC)—that is, EPS delivered by nurses—and EPS delivered by a nurse–CHW team. Previous findings from the same study sample indicated that the nurse–CHW teams were able to engage more women and deliver more services.10 Furthermore, women in the team group had significantly fewer depressive symptoms11 than did the CC group,12 with trends for higher levels of mastery13 and lower perceived stress.14
However, little is known about how mothers perceive the type of help they receive in home visits, whether mothers’ perceptions of help are consistent with program evaluations, or whether there are differences in perceptions of help based on type of home visiting provider.15 Therefore, we assessed mothers’ perceptions of the help they received from each provider group and then ranked types of help based on frequency of endorsement.
The study sample consisted of Medicaid-eligible women in Michigan who participated between 1997 and 2001 in a randomized trial prior to 24 weeks’ gestation. Women who completed at least 1 measurement after enrollment (n = 530) and also completed a patient survey at approximately 12 to 15 months after birth (n = 498) were included. We measured 32 types of help previously defined by Pharis and Levin in a study of an intensive support intervention model.16 Women were asked to rate how much help they received on a 5-point scale ranging from no help to lots of help. Each item was dichotomized as no or little help (0) or some to lots of help (1). Items were then ranked from highest to lowest percentage endorsed in both groups.
Most women were unmarried, had less than 12 years of education, and were unemployed; more than half screened positive for depressive symptoms or reported a history of abuse (Table 1). In both the nurse–CHW group and the CC group, more mothers endorsed “gave you things to read when you wanted to know something,” “helped you learn about child development,” and “taught about birth control” than other types of help (Table 2). Almost half of the women in the nurse–CHW group indicated that the program “gave you a feeling that you belonged,” “gave you a chance to let your feelings out,” “gave you a person to talk to who cared,” and “helped give your children a better start than you had”; these percentages were higher than in the CC group.
TABLE 1— Sample Characteristics at Randomization, by Study Group: Michigan, 1997–2001
| Characteristic | Community Care Group (n = 264), No. (%) | Nurse–Community Health Worker Group (n = 266), No. (%) | χ2 P |
| Age, y | .22 | ||
| < 20 | 90 (34.1) | 73 (27.4) | |
| 20–25 | 123 (46.6) | 141 (53.0) | |
| > 25 | 51 (19.3) | 52 (19.6) | |
| Race | .95 | ||
| African American | 72 (27.2) | 71 (26.7) | |
| Hispanic | 62 (23.5) | 62 (23.3) | |
| White | 110 (41.7) | 109 (41.0) | |
| Other | 20 (7.6) | 24 (9.0) | |
| < 12 y of education | 156 (59.1) | 147 (55.3) | .37 |
| Unmarried | 220 (83.3) | 218 (82.0) | .68 |
| Unemployed | 148 (56.1) | 154 (57.9) | .67 |
| Prior live birth | 143 (54.2) | 153 (57.5) | .44 |
| Unplanned pregnancy | 208 (78.8) | 208 (78.2) | .87 |
| Current tobacco use | 88 (33.3) | 85 (32.0) | .74 |
| Current drug use | 22 (8.33) | 16 (6.0) | .3 |
| Current alcohol use | 12 (4.6) | 10 (3.8) | .65 |
| History of physical abuse | 141 (53.4) | 133 (50.0) | .43 |
| Depressive symptomsa | 154 (58.3) | 145 (54.5) | .38 |
a As indicated by a score of 16 or higher on the Center for Epidemiologic Studies Depression Scale.
TABLE 2— Types of Perceived Help Reported by Respondents, Ranked in Decreasing Order of Prevalence: Michigan, 1997–2001
| Item | Community Care Group (n = 249), Rank (%) | Nurse–Community Health Worker Group (n = 249), Rank (%) |
| Gave you things to read | 1 (59.51) | 1 (71.95) |
| Helped you learn about child development | 2 (49.39) | 2 (68.72) |
| Taught about birth control | 3 (48.58) | 3 (66.39) |
| Helped keep clinic appointments | 4 (39.11) | 9 (45.71) |
| Gave you a feeling that you belonged | 5 (39.11) | 4 (66.13) |
| Chance to get feelings out | 6 (36.69) | 5 (59.51) |
| Helped with transportation | 7 (32.13) | 12 (37.40) |
| Helped give children better start | 8 (28.96) | 8 (47.09) |
| Helped to have confidence in self | 9 (26.12) | 6 (50.21) |
| Helped have a happier life | 10 (21.46) | 10 (39.84) |
| Person to talk to who cares | 11 (20.97) | 7 (47.97) |
| Helped understand self | 12 (19.76) | 11 (38.37) |
| Provided wake-up (or other reminder) calls | 13 (17.34) | 17 (25.10) |
| Helped with child care | 14 (16.13) | 22 (17.50) |
| Helped with emergency | 15 (16.13) | 14 (29.46) |
| Made phone calls to advocate for you | 16 (15.45) | 13 (29.80) |
| Helped getting a doctor | 17 (15.38) | 21 (17.96) |
| Helped get furniture | 18 (15.04) | 16 (26.23) |
| Helped getting along with family | 19 (12.90) | 23 (17.28) |
| Helped with bad habit (e.g., smoking, eating too much) | 20 (11.69) | 31 (13.11) |
| Helped plan daily schedule | 21 (11.69) | 19 (21.90) |
| Helped planning for future | 22 (11.29) | 15 (27.05) |
| Helped learn homemaking skill | 23 (9.27) | 30 (14.17) |
| Helped going back to school | 24 (9.24) | 25 (16.46) |
| Helped get along with partner | 25 (8.94) | 20 (19.17) |
| Helped understand others better | 26 (8.50) | 18 (22.04) |
| Helped find housing | 27 (7.29) | 29 (15.00) |
| Helped make new friends | 28 (5.65) | 26 (16.33) |
| Helped find job | 29 (5.65) | 28 (15.10) |
| Helped with budget | 30 (4.84) | 27 (15.16) |
| Helped with moving | 31 (4.42) | 32 (7.79) |
| Went to agency with you | 32 (3.23) | 24 (16.94) |
Adding CHWs to a team practically doubled the percentage of women who endorsed improved self-confidence (CC group, 26%; nurse–CHW group, 50%). In both groups, approximately 40% of women received help in keeping prenatal appointments (CC group, 39%; nurse–CHW group, 46%), and a third received help with transportation (CC group, 32%; nurse–CHW group, 37%). Only 13% or fewer of the women in either group endorsed the item “helped with a bad habit like smoking or eating too much.” The item “helped plan for future” was ranked higher in the nurse–CHW group than in the CC group (15% vs 22%); overall, however, individual life course items (e.g., items relating to jobs and education) were ranked lower in both groups.
Mothers who received home visits from a nurse–CHW team reported a higher percentage of help in each category of assistance than did members of a CC group. With a few exceptions, the ranking of items by frequency of help was similar for the 2 groups. About half of the mothers in the nurse–CHW group identified multiple types of psychosocial help that could be considered as promoting mental health, consistent with previous findings from the same study sample relating to depressive symptoms.12
Although mothers in each group perceived health education as the most common type of help they received, reports of help in changing health behaviors were low in both groups. Given the percentage of mothers with behavioral risks, this is an opportunity for program improvement. In both groups, items involving help with maternal psychosocial support were ranked higher than items focusing on basic needs or maternal life course issues. The lower ranking of life course items may have been due to the study women's need for more immediate, short-term help.
Few studies have examined mothers’ perceptions of help or the effectiveness of nurse–CHW team interventions, and thus it is difficult to compare our findings with previous research. One study of home visits by CHWs assessed mothers’ perceptions of assistance based on specific needs they identified at enrollment.17 Consistent with our findings, items relating to psychosocial support and information assistance were rated highest, and life course assistance items were rated lowest.
In this study, mothers’ perceptions of assistance received reinforced previous evidence from the same sample that CHWs, when partnered with nurses, have a positive impact on women's mental health. This is important because although rates of depression are higher among low-income pregnant women than among other pregnant women, rates of mental health service use are lower.18,19 Nurse–CHW home visiting models are promising and require further research.
Acknowledgments
This work was supported by the Maternal and Child Health Bureau (grant R50 MC 000 45-04 R2), the Spectrum Health Foundation (Grand Rapids, MI), and the Agency for Healthcare Research and Quality (grant 1R01 HS14206).
We acknowledge Judith Lindsay and the late Joseph Moore, the community co-investigators in the larger study on which this research is based. We thank the community health workers, nurses, Spectrum Health, and our collaborating community partners, Kent County Health Department, Cherry Street Health Services, and St. Mary's Health Care. We are especially grateful to the women who participated in the study, many of whom lived in challenging life circumstances.
Human Participation Protection
All study protocols were approved by the institutional review boards of Michigan State University, Spectrum Health, and St. Mary's Health Care. Participants provided written informed consent.
