Occupational challenges and coping strategies of public health nurses during home visits in the Ho Municipality of Ghana: a qualitative study

Abstract

Background

The Primary Health Care (PHC) clinics conduct regular home visits to assess illnesses, monitor treatment adherence, and address non-compliance cases. These visits, led by public health nurses (PHN), involve face-to-face assessments of the home environment to enhance healthcare activities, reduce default rates, and improve treatment compliance. Despite these crucial services rendered, little is known about the various challenges these professionals encounter daily. This study explored the occupational challenges faced by public health nurses during home visits in the Ho Municipality and the strategies used to overcome them.

Methods

A qualitative exploratory design was utilized to gain in-depth insights into the nurses’ experiences. Thirteen public health nurses were recruited through purposive sampling. Data was collected using semi-structured face-to-face interviews, which were audio-recorded, transcribed verbatim, and analyzed using thematic analysis.

Findings

Four main themes with 13 subthemes emerged from the data. The themes included: (1) encounters during home visits, highlighting challenges with patient engagement, environmental conditions, and cultural barriers; (2) hindrances such as lack of transportation, safety concerns, and resource limitations; (3) patient-centered strategies like active listening, empathy, and cultural sensitivity to improve patient compliance; and (4) staff-level strategies involving teamwork, peer support, and self-motivation to manage field-related stress.

Conclusion

The study offers comprehensive insights into the challenges and coping strategies of public health nurses during home visits. Addressing these issues through targeted interventions, collaborative efforts, and emotional support is crucial to enhancing the effectiveness of home-based healthcare services. Improving resources, safety measures, and support systems for public health nurses could significantly improve healthcare delivery and patient outcomes in the community.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-04979-0.

Introduction

Home visits are a key component of primary healthcare delivery, particularly in maternal and child health services, where they contribute to early detection of illness, continuity of care, and improved access to essential services [48]. Evidence from multiple settings shows that structured home visiting interventions are associated with improved maternal and child health outcomes, including increased immunization coverage, improved antenatal and postnatal care utilization, and reductions in preventable child morbidity [2, 25, 39, 46]. Evidence from systematic reviews and controlled studies indicates that home visiting interventions can improve childhood immunization coverage, with a median increase of approximately 11% points and larger gains exceeding 20% points in some controlled trial settings compared to standard facility-based care alone, while also improving early identification of childhood illnesses and maternal health education outcomes [22].

In Ghana, home visiting is implemented through the Community-based Health Planning and Services (CHPS) initiative, which serves as a key strategy for delivering preventive and promotive healthcare at the community level. Public health nurses within this system are expected to provide maternal and child health services, including health education, immunization follow-up, surveillance, and continuity of care through home visits [18, 28]. These interventions are designed to strengthen community-level healthcare delivery and improve access, particularly in underserved populations.

Despite these benefits, the effectiveness of home visiting programs is often constrained by operational and systemic challenges. Studies indicate that public health nurses frequently face difficulties such as inadequate transportation, limited medical supplies, communication barriers, and logistical constraints that affect the consistency and quality of service delivery [7, 10]. In some low-resource settings, these constraints have been associated with reduced visit coverage and interruptions in continuity of care, limiting the full impact of home-based interventions compared to earlier periods when resource availability and program support were relatively stronger.

Previous work by Dartey and colleagues in the Keta Municipality examined the experiences of community health nurses involved in home visiting programmes within a predominantly coastal and riverine setting, where geographical barriers, transportation difficulties, and dispersed settlements significantly influenced service delivery and the challenges encountered during home visits [9]. That study highlighted the types of services rendered and the contextual difficulties shaping home visiting practice in a hard-to-reach rural environment. Building on this earlier work, the current study extends the inquiry into the Ho Municipality, a semi-urban setting characterized by different socio-cultural dynamics, occupational demands, and logistical realities. While evidence from several countries demonstrates the effectiveness of home visiting programmes [9, 36, 43], much of the existing literature has focused primarily on programme outcomes and service coverage, with limited attention to the occupational challenges faced by healthcare providers and the coping strategies they adopt during implementation. Examining the experiences of public health nurses in the Ho Municipality, therefore, provides an opportunity to understand how occupational risks, workplace challenges, and adaptive coping mechanisms may differ across settings, while contributing to the growing qualitative evidence on home visiting practice in Ghana.

Therefore, this study explores the occupational challenges encountered by public health nurses during home visits in the Ho Municipality of Ghana, as well as the coping strategies they adopt in navigating these challenges. By examining nurses’ lived experiences within a semi-urban and resource-constrained setting, the study provides in-depth insight into how public health nurses manage operational difficulties while sustaining the delivery of community-based healthcare services.

Methodology

Study design

A qualitative exploratory design was adopted to facilitate an in-depth exploration of Public Health Nurses’ experiences and challenges during home visits in the Ho Municipality. This approach is particularly suitable for studies where limited prior research exists and where a comprehensive understanding of participants’ perspectives is needed [44]. It allows flexibility in data collection and analysis, enabling the researchers to capture the complexity of real-world practices and to identify emerging themes related to challenges, coping strategies, and service delivery within routine practice settings.

Study site

The Ho Municipal Assembly is one of the 18 Administrative Municipalities/Districts in the Volta Region [21]. There are about 622 workers at the Municipal Health Directorate, which is made up of 552 nurses, 10 physicians/ medical assistants, and 60 medical officers. There are 36 health facilities within the Municipality [17].

Study population and sample size determination

Public Health Nurses working in the Ho Municipality who met the inclusion criteria constituted the study population. Eligible participants included public health nurses with at least six months of experience in community-based service delivery and active involvement in home visiting activities. Nurses who were newly posted to the municipality or unavailable due to illness during the data collection period were excluded from the study.

A purposive sampling technique was employed to recruit participants with rich and relevant experience of the phenomenon under study [6]. In total, 13 public health nurses were interviewed. The sample size was determined based on the principle of data saturation, which is widely accepted in qualitative research as the point at which additional interviews no longer yield new codes or themes [29]. Consistent with this principle, data collection and analysis were conducted concurrently, allowing preliminary coding and emerging themes to be reviewed after each interview. Saturation was reached by the 11th interview, where no new themes emerged, and the final two interviews served to confirm and reinforce previously identified patterns.

To enhance variation in perspectives, participants were drawn from different health facilities and CHPS zones within the municipality and included nurses with varying levels of experience in community-based service delivery. This diversity ensured that a broad range of experiences relating to home visiting practices was captured.

Data collection method and instrument

Data were collected through in-depth semi-structured interviews with public health nurses using an interview guide developed by the authors based on relevant literature and aligned with the study objectives. The guide was piloted among three nurses in the Hohoe Municipality, and feedback from the pilot was used to refine the wording and improve the clarity and cultural appropriateness of the questions.

Following ethical approval for the study, permission was obtained from the Ho Municipal Health Directorate to conduct the research. Eligible participants who met the inclusion criteria were identified and invited to participate. Prior to the interviews, participants were informed about the purpose of the study and were assured of confidentiality, anonymity, and their right to withdraw from the study at any time without consequences. Written informed consent was obtained from all participants, ensuring adherence to the principles of informed consent and voluntarism.

Interviews were conducted in English in a quiet and private setting within the community and lasted approximately 30–45 min. With participants’ permission, all interviews were audio-recorded and later transcribed verbatim to ensure accuracy. In addition, field notes were taken during the interviews to capture contextual observations, while the researchers used reflexive journaling to enhance the credibility and transparency of the data collection process.

Data analysis

The audio-recorded interviews were transcribed verbatim and exported into Microsoft Word for analysis. The data were analyzed using inductive thematic analysis, following the procedures outlined by Polit and Beck [31]. This approach enabled the researchers to systematically examine the data to identify patterns, meanings, and insights within participants’ responses.

The analysis began with data familiarization, during which the researchers repeatedly read the transcripts to gain a comprehensive understanding of the content. During this stage, reflexivity was actively practiced as the researchers critically reflected on their own professional backgrounds, assumptions, and potential influence on data interpretation. Given that the researchers have backgrounds in public health and community health practice, there was a possibility that prior professional experiences with home visiting services could shape the interpretation of participants’ accounts. To address this, bracketing was employed by consciously setting aside pre-existing knowledge and assumptions related to public health nursing practice in order to allow participants’ perspectives to emerge inductively from the data. In addition, reflexive journaling and peer debriefing were used throughout the analysis process to continuously examine and challenge emerging interpretations, ensuring that findings remained grounded in participants’ narratives rather than researchers’ preconceptions.

Following familiarization, initial codes were generated by assigning concise labels to meaningful segments of the text. Similar codes were then grouped together and organized into preliminary themes. The themes were subsequently reviewed and refined to ensure that they accurately represented the data and aligned with the study objectives. Each theme was then clearly defined and named to reflect its central meaning. Finally, a narrative report was produced in which the themes were described in detail and supported with verbatim quotations from participants to illustrate the key findings.

Rigor

Implementing the principles of credibility, dependability, confirmability, and transferability ensured the trustworthiness of the data [26]. To enhance credibility and confirmability, member checking was conducted by sharing summary interpretations of the preliminary findings with participants to verify whether the researchers’ interpretations accurately reflected their experiences. A subset of participants reviewed and confirmed these summaries, and their feedback was used to refine and validate emerging themes.

Dependability was ensured through the use of a semi-structured interview guide applied consistently across all participants, allowing for systematic and comparable data collection procedures.

Confirmability was further strengthened through the maintenance of an audit trail and reflexive documentation of the research process, ensuring that findings were grounded in participants’ narratives rather than researcher bias.

To enhance transferability, a thick description of the study context was provided. The study was conducted within the Ho Municipality, where public health nurses operate under the Community-based Health Planning and Services (CHPS) framework. Nurses are responsible for home visiting activities in communities that include peri-urban and semi-rural settlements, often characterized by high workload demands, limited transportation support, and resource constraints within primary healthcare delivery. This contextual detail allows readers to assess the applicability of the findings to similar low-resource community health settings.

Ethical consideration

Ethical clearance was received from the Research and Ethics Committee (REC) of the University of Health and Allied Sciences, UHAS-REC A.3 [8] 23–24. Permission was obtained from the Municipal Health Directorate before the study’s commencement. Privacy and confidentiality were maintained during data collection. No personal identifiers, such as the names of participants, were recorded to ensure anonymity. Informed consent was taken from all participants. Anonymity and privacy were ensured through code-based identification instead of using names. Data confidentiality was strictly maintained for research purposes. The survey posed no risks, and participants could withdraw voluntarily. All methods and procedures were carried out in accordance with the relevant guidelines and regulations set by the REC. The study was conducted in accordance with internationally accepted ethical principles for research involving human participants, as outlined in the Declaration of Helsinki.

Results

Table 1 presents the socio-demographic characteristics of participants who consented to participate in the study.

Table 1.

Socio-demographic characteristics of participants

Variables		Frequency (N = 13)	Percentages (100%)
Age	20–29 years	4	30.8%
	30–39 years	8	61.5%
	40–49 years	1	7.7%
Marital status	Married	5	38.5%
	Single	7	53.8%
	Divorced	-	0.0%
	Co-habiting	1	7.7%
Religion	Christianity	9	69.2%
	Islam	4	30.8%
Ethnicity	Ewe	7	53.8%
	Akan	3	23.1%
	Ga-Adangbe	1	7.7%
	Hausa	2	15.4%
Rank	Public Health Nurse (N.O)	13	100%

(Field Work, 2023)

Emerged themes

In response to the research questions, the thematic analysis of the collected data yielded four main themes and fifteen subthemes as presented in Table 2. The first theme revealed their encounters during home visiting programs, while the second theme highlighted the hindrances during home visiting. The third and fourth themes explained the coping mechanisms used during home visits to overcome the challenges and provide adequate care to clients.

Table 2.

Emerging themes

OBJECTIVES	THEMES	SUBTHEMES
Explore the experiences of public health nurses during home visits.	Theme 1: Encounters During Home Visit	1. Community Resistance and Participant Reluctance 2. Bonding
Identify the challenges public health nurses face during home visits.	Theme 2: Hindrances During Home Visit	3. Unavailability of people 4. Inadequate logistics 5. Fear of potential dangers 6. Walking under harsh weather conditions 7. Misconceptions and divergent cultural perspectives 8. Geographical and language barriers
Identify the coping strategies public health nurses adopt during home visits	Theme 3: Client-centered Strategies	9. Community awareness programs 10. Referral to the clinic
	Theme 4: Staff level strategies	11. Reporting to superiors 12. Teamwork 13. Adequate planning

(FIELD SURVEY, 2023)

Theme one: Encounters during home visiting programs

As shown in Table 2, this theme revealed the varied experiences of Nurses during home visiting. They expressed sentiments of non-acceptance, encountering hostility, families being unwilling to participate, and challenges in forming connections with both patients and their families. These aspects are elaborated upon in the subsequent subthemes.

Community resistance and participant reluctance

Limited acceptance was a recurrent theme in the participants’ narratives, highlighting instances where they faced challenges in gaining acceptance within the communities they served. This lack of acceptance was particularly pronounced in larger towns, where the presence of established health facilities seemed to diminish the perceived significance of home-visiting nurses. In their narrative, they said:

Most of the time when you go into the homes, some of the clients are not willing to accept you. It’s like they are either in a hurry to go somewhere or they are not ready to listen to you. They feel they are used to whatever that you are coming to say to them. So, they don’t show much interest in the home visitor when we go and visit them. (P2)

You know Ho is an urban center, so it’s not like the home visit we do when we are in the rural areas. In Ho for instance, the acceptance is very, very low because we have a lot of hospitals. We have a lot of people who are enlightened. They choose to go to the hospital with their problems rather than to sit at home or to come to the CHPS zone and all that. So, the acceptance rate is very, very low. (P1)

Definitely, there will be some stubborn ones. Some people resist our presence, making it difficult to assess their health needs and provide the necessary support. (P10)

During home visits, communication with community members is often difficult because many people are unwilling to provide information or participate. Even after explaining the purpose of the visit and assuring them it would take only a short time, some still show little interest and give excuses for not engaging. (P7).

Aside from the general low acceptability noted, some participants experienced hostile encounters. These hostile encounters manifested in various behaviors that created challenging and, at times, uncomfortable situations for the nurses. The following represent their testimonies:

Unfortunately, not everyone welcomes us. Some residents react negatively, and it’s disheartening to face hostility when our goal is to support and improve community health. (P3)

There have been instances of a cautious reception, especially when previous interactions with healthcare providers were unsatisfactory. Earning trust in such cases requires patience and consistent efforts. (P5)

However, an alternative perspective was emphasized by other participants who suggested that community reactions were dependent on the nature of services and information provided, as well as the endorsement from community leaders.

The reception sometimes depends on the nature of the visit. Routine preventive visits might be received more openly, while visits addressing sensitive health issues may elicit more guarded responses. (P7)

Reception can be influenced by external factors, such as community leaders’ endorsements or cultural norms that shape attitudes toward healthcare professionals. (P9)

Contrastingly, some participants shared positive experiences wherein they were warmly embraced by the communities they served. The community members not only welcomed the nurses but also recognized and appreciated the value of the specialized services they provided. To this, some said:

We don’t have a problem. They are more or less farming communities. When we go, they accept us there. They don’t like coming to the facility. They prefer we come to them… and they give us that respect and receptivity because of the services we provide (P9).

So, when we go into the community, we are accepted and then they give us their cooperation. And I don’t really think we have much of a problem, just that sometimes there are things that you counsel your clients on and then it’s just difficult for them to hide it. (P10)

Bonding

Despite encountering the aforementioned negative sentiments, it’s noteworthy that certain participants managed to navigate these challenges by actively cultivating strong relationships within the communities. Through efforts focused on building trust and demonstrating unwavering commitment to their programs, these individuals successfully integrated into the community fabric. Their words are in the quotes below:

We get to meet new clients who have moved into the community and we also meet clients who have missed the previous swing sessions as well. We also get to meet people who have some chronic conditions. We meet teenagers, adolescents, and children. Even though some of them are about five years, we still have to cater for them. If you meet them in a state that is not ideal, we attend to them as well. Building trust takes time, but when they see our commitment and genuine concern, it opens doors. Residents start to see us as allies in their health journey. (P3)

My general experience. During home visits, I found that spending time building relationships with families led to increased trust. This trust facilitated open communication about health issues and improved the overall effectiveness of our interventions. I observed a positive shift during home visits as community members started actively participating in health-promoting activities (P8).

Well, home visiting is very good. Through follow up home visits, I’ve built strong relationships with families. They now feel comfortable sharing their health concerns, making it easier to provide tailored care. (P12)

Theme two: Hindrances during home visiting

This theme aims to uncover the hurdles confronted by home visiting nurses during visits. Their narratives delve into a spectrum of challenges, including the unavailability of people, insufficient logistical support, concerns about personal safety, the physical strain of walking under the sun, misconceptions held by community members, and the complexities arising from geographical and language barriers as elaborated in the subthemes below.

Unavailability of people

The insights gleaned from home visiting nurses underscore a consistent challenge: the frequent unavailability of individuals within the communities during the designated home visiting periods. The limited availability of community members during these crucial visitation times poses a substantial barrier to the effective delivery of healthcare services. Their responses are captured in the quotes below:

So, this is Klefe. We have three communities. We have Klefe Atsatime, Klefe Dome, and Klefe Demete. So, let me say three catchment areas. So, we are under the Dutaso sub-district in the Ho municipality. It’s annoying not to meet patients because many are at work, and our job becomes challenging when we can’t find them at home. Weekends are our only window, but we don’t work on Saturdays. (P11)

Sometimes you can go, and the people are already gone to work, no matter how early you set up. Sometimes you can set up as early as 6.30 am, but then when you meet the people at home, they are in a hurry. 6.30, 7.00, it’s rush hour. Everybody wants to go to work, they want to send their children to school, and all that. So, nobody literally has time for you. So, sometimes you go in the evenings, or 5.00, sometimes you can go as late as 6.00 pm, so that you will be able to meet the people at home. And surprisingly, even if you meet them at home, some will tell you they just got back from work, they are tired, they want to rest, or they want to go to church. That’s not good. Home visits here is very difficult. (P1)

Okay, with Ho and my community to be precise, one of the challenges are, you know, meeting the mothers during home visits. Most of the time, if you don’t go early, most of them move from their house to their various workplaces. Majority of them are market women, so on market days, you definitely not meet them. Either you go late in the day, later in the evening, or very early in the morning before you can’t meet them. (P3)

Inadequate logistics

Ensuring the provision of standardized care during home visits necessitates the availability of specific equipment for nurses. Unfortunately, it was disheartening and presented a significant challenge to discover that essential and fundamental equipment crucial for effective home-based care were lacking for these nurses. The absence of these vital tools not only hinders the quality of care that can be provided but also places an additional burden on healthcare professionals striving to deliver comprehensive and effective services in home settings. Participants spoke in these ways:

I do not have resources for monitoring blood pressure and diabetes, the machines are few and the one we have at the clinic we use it on rotation bases. When a client tells you can you check my blood pressure, I’m not feeling well it is a problem when you don’t have a device or a phone to call an ambulance when needed? You ask the client’s phone and afterwards you feel embarrassed when you tell them you did not have airtime’ (P4).

I don’t know, they just give us the letters to go there and trace patients and some of them are coughing, they have TB and they don’t supply us with masks to protect ourselves (P11).

The lack of the working equipment is part. Okay, so I’m talking about the lack of equipment as a challenge. And they’ve not provided it. It doesn’t… The health directorate. Okay, the health directorate. It looks like they fail to provide the working equipment. They (the health directorate) also have lack of funds at their end. They (the health directorate) also don’t have money to buy some of the things. It means that you’ve been writing to them that you need more. Yes. And from my past three days, close to one year now, our BP apparatus have not been working. (P1)

Fear of harm

Security concerns loomed large among participants, who consistently expressed anxieties regarding potential dangers in the communities they served. The isolation faced by these nurses, operating without a protective support system, heightened their apprehensions about personal safety. They recounted saying:

Most people want me to talk to their abusers but it is a difficult challenge since I’m not trained to do that. When you find a house with more than three men in a room, usually they are smoking something. In that state, they will just allow you to come in and for women, it is very dangerous because those men can even rape or rob some of our PHNs (P7).

Being harmed, we’ve heard about those instances before. Like you go to the community to provide care but at the end you get harmed. So, we are being careful when we go out there, because we are usually alone and on our own. (P11)

Walking under harsh weather conditions

The absence of logistical support, particularly the unavailability of vehicles, has compelled these nurses to navigate their way on foot under the relentless sun when visiting patient houses. The harsh weather conditions, coupled with the extended periods of walking, have emerged as significant challenges faced by these healthcare professionals. This dual burden not only exposes them to physical strain but also poses potential health risks. Some said:

We are not feeling alright because sometimes the sun is very hot. So, we feel if the department can allow one car to deliver those going there, so that they can provide services and then they can come back and take them. (P9)

We are not entitled to use the department’s car, so I and my colleagues have to walk very long distances under the hot sun (P12).

Weather conditions like we walk in the sun and it’s very hot and sometimes when it rains and we have no umbrellas people don’t let us in because we are wet (P13).

Misconceptions

Misconceptions and divergent cultural perspectives held by individuals in various communities have been consistently reported as significant hindrances. These factors contribute to a reluctance among community members to adhere to the advice and guidance provided by the nurses. The clash between healthcare recommendations and entrenched cultural beliefs or misunderstandings creates barriers to effective communication and collaboration. Participants said the following:

Misconceptions. Yeah, the misconceptions about vaccines. They hear from others. That’s what makes them… So, it’s a factor for them to be unwilling. Because when we went to, it wasn’t easy. The husband was there and she was really not ready to listen to whatever we tried to convince her. Because every child and how they react, it can be that the third dose, He will not react. But she wasn’t ready to listen. So, it’s a factor. (P2)

I think there is also an issue with how information gets to the people. Because there are some people to who has trust… They have trust issues. Somebody coming into the house because of this. The scammers. So, when somebody comes to your house and comes to ask you personal information, unless you know the person personally, it’s difficult for you to give out information. Sometimes, when you are asking certain people, they don’t really want to give you personal information because they feel like you are going to use that information to… Scam them or something. (P5)

Cultural beliefs and practices sometimes conflict with recommended medical advice, complicating health interventions. Respecting cultural diversity while ensuring evidence-based care becomes a balancing act. (P7)

Lack of awareness or health education within communities contributes to challenges. Misconceptions or limited knowledge about preventive measures impact healthcare outcomes during visits. (P8)

Geographical and language barriers

Home visiting nurses highlighted challenges in navigating through communities, coupled with language barriers that adversely impact the quality of care provided. Language barriers hinder effective communication, impeding the exchange of crucial information between healthcare professionals and community members. This is what some said:

Geographical barriers in remote areas pose significant challenges. Limited infrastructure, difficult terrain, or distance from healthcare facilities hinder regular access to healthcare services. (P6)

Few of them communicate well, but most of them language barrier. So, because of this area, I change my language to Ewe and I can communicate easily with them. (P6)

Theme three: Client-centered strategies

This theme reveals the practical strategies adopted by home-visiting nurses to maintain continuity of care and improve community engagement despite the challenges encountered during service delivery. Participants described using community awareness programs to build trust, improve understanding of their roles, and reduce resistance from community members during home visits. They also explained that referrals to health facilities served as an important alternative when essential equipment or resources were unavailable during community visits. These strategies reflect the nurses’ efforts to ensure effective healthcare delivery while adapting to logistical and community-related constraints.

Community awareness programs

Participants described community awareness programs as an important strategy for improving community acceptance and strengthening communication during home visits. Nurses explained that these sensitization activities helped community members better understand the purpose of home visits, reduced misconceptions, and promoted cooperation during service delivery. They also noted that engaging communities through education and communication enhanced their ability to interact effectively with clients in diverse settings. Their narratives are presented below:

Yeah, people in the community sometimes give us a hard time. We organize some community awareness sessions to let them know what we’re about. Opening up communication help ease them and share more about our role and why we’re there. Implementing a rotation system for different work zones has helped. This way, we’re not always walking the same long distances. It also adds variety to our work, keeping things interesting for us and the community. (P4)

Engaging in continuous training and education regarding cultural competency and communication skills has been invaluable. Strengthening these abilities enhances our effectiveness during visits. (P2)

Referral to the clinic

Participants described referral to nearby health facilities as a practical strategy for managing situations where essential equipment or logistics were unavailable during home visits. Nurses explained that referring clients to clinics ensured continuity of care and allowed patients to access appropriate assessment and treatment services that could not be provided within the community setting. This approach enabled them to maintain quality care despite resource constraints encountered during home visits. Their responses are presented below:

Since we can’t carry the digital equipment along when we are going on home visits, we ask them to come to the facility and check it themselves. Moreover, it is the same apparatus we are using at the clinic, so if we take it, those who are stationed there won’t have anything to use. And the times we want to check glucose levels, we don’t have a glucometer at the facility. So those Who want to check, we referred them. (P5)

Theme four: Staff level strategies

This theme highlights the internal and collaborative strategies employed by home-visiting nurses to manage occupational and service delivery challenges in their daily practice. Participants described relying on regular communication with supervisors, teamwork through pairing with colleagues, and careful planning of visits and resources to navigate difficult working conditions. These approaches helped nurses manage limited resources, reduce workload burdens, improve safety during community visits, and enhance the overall efficiency of home-based healthcare services.

Reporting to superiors

Participants described regular reporting to their supervisors as an important strategy for addressing challenges encountered during home visits. Nurses explained that communicating with superiors enabled them to seek guidance, report resource shortages, and request support in managing difficult situations beyond their capacity. This approach helped facilitate problem-solving, improve coordination, and ensure continuity in the delivery of home-based healthcare services. Their responses are captured in the quotes below:

I can’t solve them myself. Moreover, I am a new staff here so most times I have to report back to my in-charge. Sometimes you go to a client’s house and the situation there is so bad that you can’t help. Sometimes I help. Yeah, sometimes I help. Especially if they need this and that. They need mosquito nets. Mosquitoes are worrying. I don’t carry it along. I have to bring the nets to them…and they do come. (P6)

We inform the authorities. Those who are to provide the equipment, we let them know that we don’t have A, B, C, D. Then they also provide if it is there. If they don’t have… whenever it’s ready, they let us know. So, when they don’t bring it, that means that you can’t…They will bring it. That’s what I’m saying. If my zone is like this, we don’t have at least one or two zones that will have. (P4)

Pairing

Participants described pairing with colleagues during community visits as a practical strategy for reducing individual workload and costs while improving efficiency in service delivery. They explained that working in pairs enhanced safety, eased mobility challenges, and allowed for shared responsibility during home visits. In addition, collaboration with community leaders was reported to improve communication and strengthen acceptance of services within the community, thereby facilitating more effective engagement during fieldwork. Their responses are presented in the quotes below:

To address the long walks, I’ve initiated a buddy system. We pair up and share transportation costs. It’s made a significant difference, and we can now focus more on providing care to the communities. (P9)

Establishing strong community partnerships has proven to be a successful strategy. Collaborating with local organizations or community leaders helps in addressing challenges and accessing resources effectively. (P3)

A participant offered a valuable suggestion for collaboration between the health directorate, non-governmental organizations (NGOs), and the communities to enhance the home visiting program. He said:

I think the health directorate, NGOs, or even the communities can come together and then look for ways to provide us with the essential things we need to make home visiting easier. Especially the home visiting. And they should try to get people to come. And then, I think we also have work to do as nurses to give more education so that people will be able to accept us. Okay. So, those are my final words. (P1)

Adequate planning

Participants described adequate planning as a key strategy for managing the challenges associated with home visiting. They explained that careful preparation before field visits helped them anticipate potential difficulties, allocate limited resources more effectively, and prioritize households based on need. This forward-looking approach enabled nurses to optimize their time, reduce inefficiencies, and adapt their activities to the realities of resource constraints in the field. The quotes below represent their narratives:

Implementing proactive planning by anticipating potential challenges before visits helps in preparing necessary resources or alternative approaches, ensuring smoother interactions. (P7)

The challenges will always be there, no one is going to provide everything. So, it is all about planning. Planning on how to use the little we have judiciously. Planning on when to go to the community and when not to, depending on your assessment. (P3)

Discussion

This study explored the occupational challenges encountered by public health nurses during home visits in the Ho Municipality of Ghana, with a particular focus on the challenges they encounter and the coping strategies they employ in delivering community-based care. The findings are presented under key themes and subthemes, which are discussed in relation to existing literature and the study objectives.

The prevalent subtheme of low acceptability in home visiting programs sheds light on the emotional challenges faced by public health nurses, particularly in urban areas like Ho. The study reveals that the abundance of established health facilities in larger towns diminishes the perceived importance of home visits, leading to a sense of reduced acceptance among nurses. This emotional aspect aligns with existing literature on the emotional experiences of healthcare workers in community-oriented healthcare settings [23]. Some participants had hostile encounters during home visits. This aligns with existing literature on the emotional toll and complexities involved in providing healthcare in settings where acceptance is lacking [16, 30]. Additionally, some beneficiaries of the program expressed reluctance, portraying an apparent unwillingness to participate in the program during home visits.

Despite the above negative experiences, some participants felt accepted in farming communities. This underscores the contextual nature of community perceptions and suggest the potential for successful integration in certain settings [8, 40]. Successful participants in home visiting programs demonstrated the importance of building trust and maintaining unwavering commitment within communities. Trust-based connections not only improved reception but also significantly enhanced the effectiveness of home-visiting nurses’ initiatives [34]. Relationship building facilitates open communication about health issues and increases community participation in health-promoting activities [45].

The identified hindrance of the unavailability of individuals during home visiting periods poses a consistent challenge for healthcare professionals engaged in home-based care. This challenge is not unique and has been noted in similar contexts, with studies emphasizing the difficulties healthcare professionals face in reaching individuals during work hours or other busy periods [13]. Participants in the study highlighted the limited availability of community members during these crucial visitation times as a significant obstacle to the effective delivery of healthcare services [19].

The inadequacy of logistics presents a significant challenge for home-visiting nurses, impacting the delivery of standardized care during home visits. Unfortunately, essential equipment crucial for effective home-based care, such as blood pressure and diabetes monitoring devices, as well as personal protective gear, particularly masks for infectious diseases like TB, is insufficient, hindering the quality of care [14].

Also, logistics in terms of vehicles have compelled home-visiting nurses to navigate on foot under the relentless sun when visiting patients’ houses. This dual burden of harsh weather conditions and extended periods of walking has emerged as a significant challenge for these healthcare professionals, exposing them to physical strain and potential health risks. Research on the impact of working conditions on healthcare professionals and the effectiveness of logistical support in home-based care may offer valuable insights [32, 42]. Security concerns emerged as a prominent issue among participants, reflecting anxieties about potential dangers in the communities they served. The isolation experienced by these nurses, operating without a protective support system coupled with geographical barriers and language obstacles, heightened their apprehensions regarding personal safety [1, 12]. The absence of safeguarding mechanisms left them vulnerable to various risks, contributing to a pervasive sense of unease during their service delivery [24, 47]. Existing literature on healthcare worker safety and risk management may provide additional insights into addressing these concerns [15]. Misconceptions and divergent cultural perspectives in various communities consistently hinder effective communication and collaboration with home-visiting nurses, contributing to a reluctance among community members to adhere to the provided advice and guidance. The clash between healthcare recommendations and entrenched cultural beliefs or misunderstandings creates significant barriers [20]. Relevant literature on cultural competence in healthcare and strategies for overcoming misconceptions may offer valuable insights [37].

Home-visiting nurses take a proactive approach to community challenges through awareness sessions, enhancing understanding and cooperation with community members. A rotation system for work zones is recognized as strategic, overcoming challenges associated with long distances and maintaining community interest [38]. Participants address inadequate logistics by adopting a patient-centered approach and strategically referring patients to the nearest clinic or their own clinics during home visits. This adaptive strategy ensures individuals receive necessary care, overcoming resource limitations [35]. This approach reflects a commitment to resource optimization and aligns with healthcare best practices, emphasizing access to appropriate care in resource-constrained environments [49]. Participants exhibit a consistent practice of promptly reporting to superiors, showcasing a proactive communication approach for streamlined home-based healthcare initiatives. Notably, participants, particularly those newly assigned, emphasize reporting challenging situations to their in-charge, fostering collaborative communication [11, 33]. This dedication to open communication aligns with best practices in healthcare management, emphasizing its pivotal role in successful community healthcare initiatives [41]. Participants strategically form pairs during community visits to optimize service delivery, reducing costs and emphasizing resourcefulness. Collaboration with community leaders and organizations enhances communication and overall effectiveness in healthcare delivery. These findings align with best practices, emphasizing collaborative approaches and resource optimization for successful home-visiting programs [3, 4].

Participants underscored the vital role of adequate planning as a strategic coping mechanism in home visiting programs. This proactive approach involves careful preparation, enabling nurses to navigate challenges effectively [5]. These insights align with best practices in healthcare management, emphasizing the significance of planning for successful community healthcare initiatives [27].

Limitation of the study

The study’s findings are limited by its small sample size and focus on a single municipality, which may limit transferability to other settings. Conducting interviews primarily in English may have constrained participants’ full expression of their experiences. In addition, reliance on self-reported accounts introduces the possibility of response bias.

Conclusion

The study provides comprehensive insights into the multifaceted challenges and strategies in home-visiting programs. The emotional experiences of nurses, hindrances faced during visits, patient-centered strategies, and service-rendering tactics collectively contribute to a deeper understanding of the complexities of home-based healthcare. Addressing these challenges requires a holistic approach, integrating emotional support, targeted interventions, and collaborative efforts.

Implications for public health nursing

Educational programs should prioritize emotional resilience, trust-building, and cultural sensitivity in home-based care. Future research should explore the emotional experiences of urban healthcare workers, with a focus on strategies to improve community acceptance. Policy recommendations should advocate for comprehensive support systems, including safety measures and logistical assistance, to address risks and challenges faced by home-visiting nurses.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

A.F.D. conceptualized the study, provided supervision, contributed to the original draft preparation, and reviewed and approved the final manuscript. P.T. developed the methodology, conducted the literature review, contributed to the original draft, and reviewed and approved the final manuscript. F.M.S. and J.Y.O. performed formal data analysis and interpretation of findings, contributed to drafting the manuscript, and reviewed and approved the final manuscript. V.B. assisted with data collection and transcription, contributed to manuscript drafting, and reviewed and approved the final manuscript. T.A.D. coordinated the study, supervised data collection, contributed to manuscript drafting and editing, and reviewed and approved the final manuscript.

Funding

The study was self-funded by the authors. No financial support was received for the study.

Data availability

Available data can be obtained with permission from the UHAS Research Ethics Committee.

Declarations

Ethics approval and consent to participate

The study received ethical approval and review clearance from the Research Ethics Committee of the University of Health and Allied Sciences (UHAS), under reference number UHAS-REC A.3 [8] 23–24. Participants were assured of confidentiality and their right to withdraw from the study whenever they wished; hence, the principles of informed consent and voluntarism were strictly adhered to, and written informed consent was obtained from all participants before participating in the interviews. The study was conducted in accordance with internationally accepted ethical principles for research involving human participants, as outlined in the Declaration of Helsinki.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.