A qualitative assessment for planning the implementation of a social needs intervention in community-based home...

BackgroundSocial determinants of health (SDOH) and related social needs (e.g., food insecurity, financial strain) are major drivers of maternal health disparities. Pregnant women of color and those with low socioeconomic status (SES) experience a disproportionate burden of social needs, which are associated with adverse pregnancy outcomes and increased risk of chronic disease for both mothers and children. Home visiting programs represent a promising, community-based platform for identifying and addressing social needs; however, little is known about how these processes occur in practice or how they can be strengthened.ObjectivesExplore how social needs are identified and referred for intervention within the Parents as Teachers (PAT) home visiting model.DesignQualitative.MethodsWe conducted semi-structured interviews with supervisors, parent educators (home visitors), and pregnant women of color and low SES participating in PAT across seven U.S. states. Interview guides and analysis were informed by the Consolidated Framework for Implementation Research (CFIR) and the Healthy People 2030 SDOH framework.ResultsParticipants (25 PAT providers; 15 pregnant women) described social needs as pervasive and central to maternal well-being, with limited and variable community resources. Determinants spanned multiple CFIR domains. In the outer setting, availability of community resources and interorganizational partnerships shaped referral success. In the inner setting, time constraints, inconsistent resource tracking systems, and variable infrastructure posed barriers. At the implementer level, educators reported role strain and uncertainty regarding scope of practice, while noting that trusting relationships facilitated disclosure of sensitive needs.ConclusionHome visiting programs are uniquely positioned to identify and address social needs through longitudinal, relationship-based engagement. Findings highlight the need for brief assessment processes; enhanced training and role clarity for home visitors; and systems to support resource management and partnerships. These insights can inform scalable social needs interventions within home visiting to advance maternal health equity.