An exploration of how long-term preventive home visits affect older persons’ health and possibility for a good life in their own homes. Users’ and service-providers’ perspectives

Abstract

Preventive home visits (PHV) is health care services to independently living older persons, which aim to promote health, prevent disease and functional decline, and uphold older persons’ ability to stay in their own homes. The first PHV services were developed in Denmark and UK more than 50 years ago, while the first Norwegian municipalities introduced PHV in the 1990’s. Currently, most western countries offer variants of PHV, and the expected demographic changes have led to an increased interest in these services. In 2013, 25% of Norwegian municipalities offered variants of PHV, but the interest is rising due to governmental encouragement.

Before this study, no Norwegian studies on PHV were found. International researchers had made several systematic reviews based on RCTs to assess effects of PHV and define characteristics related to successful services. These studies demonstrated that PHV may improve several health related aspects, but failed to produce recommendations for how to design and carry out effective PHV services. Consequently, other research methods were called for to produce more in-depth knowledge about PHV. A widespread PHV model in Scandinavia is to offer annual visits to a general population of older persons. Studies that explore the experiences and opinions of those involved in PHV services might provide information on what is going on in these visits, and what contribute to benefits for the users.

The main aim of this PhD study was therefore to explore how long-term preventive home visits affect older persons’ health and possibility for a good life in their own homes. The study was based on a comprehensive understanding of health and health promotion. We studied a Norwegian PHV service where ten experienced nurses had offered annual home visit to home-dwelling older citizens for more than ten years. The study applied an explorative case study design with a multiple methods approach, comprising three sub-studies. Study one had a qualitative, hermeneutical approach using individual research interviews, and explored ten PHV users’ perceived benefits from the service after six or more years of follow up. Findings from this explorative study were used to develop a questionnaire, which subsequently was applied in a quantitative cross sectional survey. In this second study, a representative sample of 161 PHV users with experience from two or more visits evaluated the service, answering questions about the perceived benefits defined in study one. The study also explored if perceived outcomes of the PHV service varied according to socio-demographic or health related factors. The third study explored the nurses’ experiences of benefits from long-term PHV follow-up, and their perspectives on what was important for the creation of benefits in a long-term perspective.

The study have identified outcomes from PHV that older persons judged as valuable. The service providers supported the users’ striving to maintain themselves as persons, and provided personally tailored support that added to older persons’ feeling of safety, their perceived self-worth, their ability to manage everyday life and to live good lives in their own homes. The survey confirmed that many PHV users shared these benefits and valued the service highly. Socio-demographic and health related conditions had only minor impact on perceived outcomes of PHV, and we found no support for restricting the service to special subgroups of older people. The study of the nurses’ perspectives confirmed that the PHV offered individualised, longitudinal support that could lead to a variety of benefits for the users and contribute to sustained ability to live independently and thrive in own home despite age-related changes. The study also illuminated complex relational and professional processes and structural and contextual factors involved in creating benefits for the users.

In case studies, convergence of evidence from the sub-studies can give an extended understanding of the research aim. Findings across the studies supported a comprehensive understanding of health and health promotion when designing effective and helpful PHV, and when evaluating such services. A synthesis of objective health as absence of disease, subjective health as well-being, and health as a resource for coping and a good life open for abroad repertoire of preventive and health promotive strategies necessary for individual targeting of the service and supporting each user’s needs and valued goals. Findings across the sub-studies have also resulted in a model illustrating the factors that influenced the creation of benefits from the long-term PHV service. Finally, the knowledge gained through this PhD study and relevant literature have resulted in a generalised model to guide implementation, further development and evaluation of PHV services.

The knowledge are relevant in Norway and other countries with similar health-care systems and socioeconomic conditions. The knowledge from this PhD thesis can support decisions about PHVs, and inform development of effective PHV services that support older persons’ possibilities for a long and good life in their own home, which is important from each older persons’ point of view, from a public health perspective and from a socioeconomic perspective.