RESEARCH AND PRACTICE
Maternal Perceptions of
Help From Home Visits
by Nurse–Community
Health Worker Teams
Lee Anne Roman, PhD, MSN, Jennifer E. Raffo,
MA, and Cristian I. Meghea, PhD
We used data from a home visit-
ing trial to examine low-income
women’s perceptions of services
received from nurses (the commu-
nity 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 re-
ceived. A higher percentage of
women in the nurse–CHW group
than the CC group reported that
they received psychosocial help.
(Am J Public Health. 2012;102:
643–645. doi:10.2105/AJPH.2011.
300455)
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 pro-
vide 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 inter-
vention in the context of a Medicaid, state-
sponsored enhanced prenatal and infant
services (EPS) home visiting program in Mich-
igan. Given low enrollment in EPS during
pregnancy (only 28% of Medicaid-enrolled
women in Michigan participated in EPS), the
April 2012, Vol 102, No. 4 | American Journal of Public Health
team intervention was designed to use CHWs
to improve engagement, increase service de-
livery, 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 com-
paring 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 Further-
more, women in the team group had significantly
fewer depressive symptoms11 than did the CC
group,12 with trends for higher levels of mas-
tery13 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 pro-
vider.15 Therefore, we assessed mothers’ per-
ceptions of the help they received from each
provider group and then ranked types of help
based on frequency of endorsement.
METHODS
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 en-
rollment (n = 530) and also completed a pa-
tient survey at approximately 12 to 15 months
after birth (n = 498) were included. We mea-
sured 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.
RESULTS
Most women were unmarried, had less than
12 years of education, and were unemployed;
Roman et al. | Peer Reviewed | Research and Practice | 643
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 de-
velopment,” 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.
Adding CHWs to a team practically doubled
the percentage of women who endorsed im-
proved 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 en-
dorsed 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.
DISCUSSION
Mothers who received home visits from
a nurse---CHW team reported a higher per-
centage 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 behav-
ioral risks, this is an opportunity for program
 RESEARCH AND PRACTICE

improvement. In both groups, items involving

TABLE 1—Sample Characteristics at Randomization, by Study Group: Michigan, 1997–2001 help with maternal psychosocial support were
Community Care Group Nurse–Community Health Worker ranked higher than items focusing on basic
Characteristic (n = 264), No. (%) Group (n = 266), No. (%) v2 P needs or maternal life course issues. The lower
ranking of life course items may have been
Age, y .22
due to the study women’s need for more
< 20 90 (34.1) 73 (27.4)
immediate, short-term help.
20–25 123 (46.6) 141 (53.0)
Few studies have examined mothers’ per-
> 25 51 (19.3) 52 (19.6)
ceptions of help or the effectiveness of nurse---
Race .95
CHW team interventions, and thus it is difficult
African American 72 (27.2) 71 (26.7)
to compare our findings with previous re-
Hispanic 62 (23.5) 62 (23.3)
search. One study of home visits by CHWs
White 110 (41.7) 109 (41.0)
assessed mothers’ perceptions of assistance
Other 20 (7.6) 24 (9.0)
based on specific needs they identified at
< 12 y of education 156 (59.1) 147 (55.3) .37
enrollment.17 Consistent with our findings, items
Unmarried 220 (83.3) 218 (82.0) .68
relating to psychosocial support and information
Unemployed 148 (56.1) 154 (57.9) .67
assistance were rated highest, and life course
Prior live birth 143 (54.2) 153 (57.5) .44
assistance items were rated lowest.
Unplanned pregnancy 208 (78.8) 208 (78.2) .87
In this study, mothers’ perceptions of assis-
Current tobacco use 88 (33.3) 85 (32.0) .74
tance received reinforced previous evidence
Current drug use 22 (8.33) 16 (6.0) .3
from the same sample that CHWs, when
Current alcohol use 12 (4.6) 10 (3.8) .65
partnered with nurses, have a positive impact
History of physical abuse 141 (53.4) 133 (50.0) .43
on women’s mental health. This is important
Depressive symptomsa 154 (58.3) 145 (54.5) .38
because although rates of depression are
a
As indicated by a score of 16 or higher on the Center for Epidemiologic Studies Depression Scale. 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. j

TABLE 2—Types of Perceived Help Reported by Respondents, Ranked in Decreasing About the Authors
Order of Prevalence: Michigan, 1997–2001 The authors are with the Department of Obstetrics, Gyne-
cology, and Reproductive Biology, College of Human
Community Care Group Nurse–Community Health Worker Medicine, Michigan State University, East Lansing.
Item (n = 249), Rank (%) Group (n = 249), Rank (%) Cristian I. Meghea is also with the Institute for Health Care
Studies, Michigan State University.
Gave you things to read 1 (59.51) 1 (71.95) Correspondence should be sent to Lee Anne Roman,
Helped you learn about child development 2 (49.39) 2 (68.72) PhD, MSN, Michigan State University, College of Human
Medicine, Department of Obstetrics, Gynecology, and
Taught about birth control 3 (48.58) 3 (66.39) Reproductive Biology, 630 East Fee Hall, East Lansing,
Helped keep clinic appointments 4 (39.11) 9 (45.71) MI 48824 (e-mail: lroman@msu.edu). Reprints
Gave you a feeling that you belonged 5 (39.11) 4 (66.13) can be ordered at http://www.ajph.org by clicking the
“Reprints/Eprints” link.
Chance to get feelings out 6 (36.69) 5 (59.51) This article was accepted September 4, 2011.
Helped with transportation 7 (32.13) 12 (37.40)
Helped give children better start 8 (28.96) 8 (47.09) Contributors
Helped to have confidence in self 9 (26.12) 6 (50.21) L. A. Roman originated the larger study, was involved in
Helped have a happier life 10 (21.46) 10 (39.84) all aspects of its implementation, and led the conceptu-
alization of the study, interpretation of the results, and
Person to talk to who cares 11 (20.97) 7 (47.97) the writing of the article. J. E. Raffo and C. I. Meghea
Helped understand self 12 (19.76) 11 (38.37) conducted the analysis, participated in interpreting the
Provided wake-up (or other reminder) calls 13 (17.34) 17 (25.10) findings, and contributed to the writing of the article.

Helped with child care 14 (16.13) 22 (17.50)

Helped with emergency 15 (16.13) 14 (29.46) Acknowledgments
This work was supported by the Maternal and Child
Made phone calls to advocate for you 16 (15.45) 13 (29.80) Health Bureau (grant R50 MC 000 45-04 R2), the
Spectrum Health Foundation (Grand Rapids, MI), and
Continued the Agency for Healthcare Research and Quality (grant
1R01 HS14206).

644 | Research and Practice | Peer Reviewed | Roman et al. American Journal of Public Health | April 2012, Vol 102, No. 4

TABLE 2—Continued
Helped getting a doctor
Helped get furniture
Helped getting along with family
Helped with bad habit (e.g., smoking, eating too much)
Helped plan daily schedule
Helped planning for future
Helped learn homemaking skill
Helped going back to school
Helped get along with partner
Helped understand others better
Helped find housing
Helped make new friends
Helped find job
Helped with budget
Helped with moving
Went to agency with you
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.
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