Teaching about home visits to university students

Objetivo : identificar as evidencias cientificas diponiveis na literatura  sobre as estrategias de ensino utilizadas na tematica de  visita domiciliar. Metodos : revisao integrativa da literatura realizada na Base de Dados da Enfermagem, Cientific Electronic Library Online , Literatura Latino-Americana e do Caribe em Ciencias da Saude e Cumulative Index to Nursing & Allied Health Literature . Resultados: foram incluidos seis artigos, com  nivel VI de forca de evidencia. Encontrou-se diferentes estrategias e metodos de ensino relacionados a atividade de visita domiciliar como sociodrama, metodologias ativas e a realizacao de praticas curriculares na rede de servicos de saude. Vivenciar a realidade social  foi uma potencialidade  encontrada pelos estudantes e,  como fragilidade, a falta de planejamento da visita. Conclusao : a principal estrategia de ensino para estudantes universitarios da area da saude e  a insercao precoce para o acompanhamento direto de familias por meio de visitas domicilares.


Introduction
As one of the guidelines of the Family Health Strategy, family care advocates that care should be centered on the family nucleus (1) , understood and perceived from its physical and social environment, allowing health teams an expanded understanding the health-disease process and the need for interventions that go beyond curative practices (2) .
The family should be seen as a unit of singular care by the peculiarities in its dynamics since it constitutes an essential nucleus in the maintenance of the health and life of its members. The home visit is highlighted among the tools for approaching the individual, the family and the community, in the context of the Family Health Strategy. This is a set of health actions aimed at both educational and care, as well as being an activity used to subsidize interventions in the health-disease process of individuals or the planning of actions, aiming to promote the health of the population, the family and the community (2) . Also, it is characterized as a set of actions that prioritize guidelines for self-care, maintenance, and health promotion, monitoring of injuries, specific situations, temporary or not, as well as monitoring of other situations in the family context (3) .
The inclusion of students in Primary Health Care teams during training is one of the educational strategies adopted in undergraduate health courses. Also, home visits by students may prove to be an important tool in building the skills required for the exercise of health professions (4) .
The home visit is an activity bringing students closer to the local reality and people, a better understanding of their problems, needs and ways of life, allowing the student to better understand the social, economic and cultural dimensions that surround the health-disease process, constituting an important educational or pedagogical strategy in the construction of competencies that favor an expanded health view (4) .
It is an opportunity to understand the user's way of life better; knowing the environment and in-tra-family relationships; addressing issues that go beyond physical illness and also addressing social and emotional problems; providing guidelines that are more focused on the individual´s real health needs and looking for singularities in the way of caring (5) .
Thus, it is fundamental that the university students of the health area acquire knowledge to practice the home visit in their training process. The visit has the potential to make them more humanized health professionals as an important tool to approach the family.
The objective of the study was to identify and analyze the scientific evidence available in the literature on home visits as a teaching strategy.

Methods
This is a literature integrative review, carried out with the purpose of gathering and synthesizing research results on a given topic or issue, in a systematic and orderly manner, contributing to the deepening of the knowledge of the subject investigated (6) .
The review was developed in five phases, according to the proposal presented by researchers (6) . The phases are: 1) identification of the theme and selection of the research question; 2) establishment of inclusion and exclusion criteria of articles (literature search); 3) definition of the information to be extracted from the selected studies; 4) evaluation of selected studies; 5) analysis and synthesis of the results and presentation of the review.
The following guiding questions were formulated to guide the integrative review: how has the teaching and learning process been developed about home visits to university students in the health area in the context of Primary Health Care? What are the potentialities and weaknesses using this tool for the teaching of university students in the health area in the context of Primary Health Care?
Because this study is an integrative review of the literature, it is considered relevant the use of keywords obtained from the Health descriptors and key-words to obtain an increase in the search for publications and the most reliable results. Thus, the following descriptors, their combinations and the Boolean operator represented by the term And connector were used to search for articles: home visit, Family Health Strategy, Primary Health Care, teaching and students and the keyword: Family Health Program. The search for scientific publications was carried out in the following databases: Nursing Database (BDENF); Scientific Electronic Library Online (SCIELO); Latin American and Caribbean Literature in Health Sciences (LILACS) and Cumulative Index to Nursing & Allied Health Literature (CINAHL).
The inclusion criteria for the selection were published articles in Portuguese, Spanish, and English; available in full text and published from January 2005 to December 2015. Those who answered the guiding questions were selected from their reading in full. However, the exclusion criteria were the studies that did not respond to the guiding and thematic question, as well as duplicate publications.
The data extracted from the selected publications were transcribed into a validated instrument and adapted to meet the study objective. The instrument contained variables of interest of the research whose items were article, objective; method; population; results; conclusions and level of evidence (7) .
The selected studies were submitted to a level of evidence classification (8) , consisting of 7 levels: 1) evidence obtained from a systematic review or meta-analysis of randomized, controlled clinical trials or clinical guidelines based on systematic reviews of randomized controlled trials; 2) evidence from at least one well-delineated, randomized, controlled clinical trial; 3) evidence from clinical trials, without randomization, well delineated; 4) evidence obtained from well-delineated cohort and control case studies; 5) evidence that originated from a systematic review of descriptive and qualitative studies; 6) evidence from a single descriptive or qualitative study and 7) evidence from the opinion of authorities or expert committee reports. According to this classification, levels 1 and 2 are considered strong evidence; 3 and 4 as moderate; 5 to 7 as weak.
The last stage consisted of presenting the main results obtained, which were analyzed according to the theme of a home visit (9) . This stage is considered of extreme importance because it has an impact on the current knowledge about the subject, allowing the collection of gaps, suggesting future scientific research (10) .
Initially, a total of 374 scientific articles were found. After reading the titles and the abstracts, 239 scientific publications that did not approach the theme or were duplicate articles were excluded. A total of 135 articles were read. Of them, 129 were excluded, since the studies were not carried out with health students in Primary Care and did not present the potentialities and weaknesses in the practice of teaching home visiting. Thus, a final sample of six publications aimed at teaching and learning from home visits was obtained, four articles from the LILACS database and two from SCIELO.

Results
Regarding the year of publication, two articles were found in 2013, and one article was published in 2009, 2011, 2012 and 2015. As for the undergraduate course, two were of Medicine, two of Medicine and Nursing, one of Physiotherapy and another study of Dentistry. Figure 1 summarizes the studies included in this review.
In the study A1 (11) , the use of the socio-drama technique enabled to identify the main themes brought by the students in the dramatizations about home visits, such as fighting and violence; misery and lack; disappointment and disinterest; impotence and failure; rejection and mistrust. Thus, many feared situations and emotions rarely addressed in medical courses could be experienced and elaborated in a few hours. This sociodramatic experience of preparation for home visits exposes the need to prepare the medical graduate to get in touch with all the complexity of the multiple determinants of the health-disease process and the interdisciplinary and cross-sectoral perspective of health care, as well as what it is fundamental to learn from the beginning of the course of communication skills and multi-professional teamwork.
On the other hand, the study A2 (12) shows that the patients consider as positive the home visit performed by the Medicine and Nursing students since their performance goes beyond the physical care and point out the importance of interpersonal relationships in the context of health care. From the point of view of the families, the visits enable the teaching and the learning process being that they express the senses of the teaching both by the specific knowledge that the students present and by the experience of life, revealing a learning not only of the school but also the need of the younger people learn from their elders. It is understood that the home visit increases the interactivity between the health service and the patient and develops according to the principles of humanization. However, attention should be paid to the importance of continuous improvement in the planning and implementation of home visits.
In the study A3 (13) , the authors identified three thematic categories that emerged from the reports of physiotherapy students. They are the experience of the home visit in primary care and the reorientation of the professional training of the physiotherapist; primary care and a home visit in the perspective of the humanization of physical therapy and the resignification of the home visit in the construction of learning. The experience of the home visit in primary care and the reorientation of the professional training of the physiotherapist arose to the extent that the trainees were inserted in the primary care, having the home visit as a tool for reflection and the transformation of thinking and doing in health, which allowed inferring a new perspective in the reorientation of vocational training. The second thematic axis, the primary care and the home visit from the perspective of the humanization of physical therapy, involves the relation of reception and the link between therapist and patient in the co-responsibility, in the health-disease process of the community. The third thematic axis that guides the interpretation and discussion of the text is the resignification of the home visit in the construction of learning, igniting the discussion for the deconstruction of concepts related to the presence in basic care and to the reevaluation of the home visit as an important tool for learning in service construction.
The study A4 (14) brought important results of a study carried out with medical students to evaluate the impact of the home visit on the process of teaching and learning in the community. The students´ perceptions were analyzed in reality lived by them, through data collection instruments, such as interviews, focus groups of students and teachers, analysis of evaluation reports. The results showed that when the medical visit is complemented by the visit to the family at home, the students become more motivated and active, and the home visiting strategy has an impact on the social profile of students and future professionals in the health area. Its application is relevant to the teaching of Social Pediatrics and Medicine in general.
The study A5 (15) compared the opinion among undergraduate students in Medicine and Nursing, the second grade of the School of Medicine of Marília and the families of the area covered by the health unit of the Santa Antonieta II family, who received Students´ home visits. The objectives of this study were to evaluate the students' satisfaction with the professional practice activity and to describe the impacts and changes in the health-disease process that the activity provided to the families. The results show that home visits promote a greater bond between students and families. These results consider important the home visits for the valorization and improvement of the practice, aiming at the humanized construction of the health-disease process, encouraging the academic formation and the integral bond between health professional and patient from the beginning.
The study A6 (16) , aimed to know the perception of students of the dentistry course in the practice of collective health, shows a different understanding of the importance of home visits as a teaching practice, in which students recognize that the visit contributes to the knowledge of social reality and for others this practice does not prove important for their training. Also, most of them point out that these activities have little contribution to community residents.
Home visits should provide activities that extrapolate the collection of data from families in the community, allowing the student's relationship with the family to develop in the logic of the humanization of care. Teachers from all areas of knowledge should consider proposals that extrapolate clinical care as a set of technical procedures for a proposal in which these activities effectively impact on oral health, leading to a greater link with this population (9) .
The studies point out potentialities in the use of the home visit as an educational strategy for undergraduate students of the health area, in the practice of teaching in primary care. These potentialities have been described as (re) knowing health problems (A1 (11) , A2 (12) , A5 (15) , A6 (16) ) and establishing behaviors according to the patients' living conditions by listening feelings of the relationship with patients and their relatives (A1 (11) ); to develop interaction, bonding and reflection on the health needs of families and to allow a broader view of the determinants of the health-disease process, including socioeconomic, environmental, physical and emotional health (A2 (12) , A3 (13) , A5 (15) , A3 (16); in the extra class spaces, the student experiences the facts and presents more conditions to make the diagnosis and the treatment appropriate to the reality of the patients; Encouraging the student to become a more autonomous subject in the process of formation in contexts of uncertainties and complexities (A3 (13) ); it allows students to develop hypotheses, socialize and become active subjects in the construction of their knowledge, to promote meaningful learning (A4 (14) ); to allow the attachment of the student to the family and promotes the humanization of care, based on the affective and trusting relationship (A6 (16) ). Regarding the weaknesses, the studies present different factors, such as a feeling of impotence in the social needs of the patients, in which the possibility of interdisciplinary and cross-sectorial attention is not known as mediator of the health care and difficulty of understanding the student´s role as facilitator of the family bond (A (11) ); need for greater organization and planning of the home visit (A2 (12) ); home visits are sporadic and of short duration, often carried out focusing on the individual and not on the family. Moreover, they do not enable to establish a social commitment and to create strong bonds, since the student´s involvement with the family is of short duration (A5 (15) , A6 (16) ).

Article Objective Type of study Method/Population Main results
Level of evidence A1 (11) Describing the visits experience of the 1 st year students of Botucatu-Unesp School of Medicine.
Descriptive, of a qualitative nature.
Sociodrama, a technical resource belonging to the set of strategies used in psychodrama. Held with ninety students of the 1 st year of Medicine.
The main themes brought by the students in the dramatizations were: a) fight and violence; B) misery and lack; C) impotence and failure.
VI A2 (12) Analyzing on the visits made by medical and nursing students from the perspective of the patients of family health units.
D e s c r i p t ive , ex p l o ra to r y, qualitative in nature.
The 1 st and 2 nd -year undergraduate Nursing and Medicine students were enrolled in the family health units, in groups and monitored ten families, in a period of two years.
The patients point out the performance of students that goes beyond physical care as positive. As a limitation, they indicate the need for greater planning of the visit.
VI A3 (13) Understanding the meanings attributed to home visiting activity for health care in the teaching process.
D e s c r i p t ive , ex p l o ra to r y, qualitative in nature.
Eight trainees underwent home physiotherapeutic care within the scope of a family health team.
The focal group technique was used, recorded and transcribed for later analysis and interpretation of the data, which originated guiding axes.
VI A4 (14) Evaluating the impact of home visits for the process of comprehensive learning training.
Q u a l i t a t iveinterpretive, of the Case study type.
Implementation of active methodology, based on the solution of simulated or real problems, case studies, and home visits. It was performed in the Social Pediatric subject.
The results showed that when the medical appointment is complemented by the visit to the family, the students became more motivated and active. VI A5 (15) Comparatively evaluating the opinion of the students and the families performing and receiving home visits. D e s c r i p t i v e and quantitative.
Nursing and Medicine students and two teachers were inserted in the network of municipal health services, which allowed the students experience.
For most students, the bond between families increased and those who received home visits over the years would like to receive more visits in the coming years. VI A6 (16 ) Knowing the perception of the Dentistry students on the learning in the collective oral health area and their involvement with the community, experienced in the activities. D e s c r i p t ive , quantitative, cross-sectional.
Proposal to include disciplines and internships focused on collective health that contemplate training based on integration with public health services, an approximation to the reality of the health-disease process. Made with 104 students of the last year.
For 36.3% of the students, home visits contribute to the recognition of social reality; 36.3% of the students did not recognize in the visits any importance for their training.

Discussion
The selected studies showed the recognition that the home visit is a beneficial strategy for the teaching and learning of health students, particularly in the first periods of the courses. It was considered that the home visit promotes the approximation of the social environment in which people live, becoming a facilitating instrument for a more reliable understanding of reality, being possible to know the human being in its multiple dimensions and not only the biological, as usually occurs at more specialized levels of health care (13) . Home visits are an important way for students to understand their role as a supporting citizen in the process of transforming reality through the commitment to health and quality of life of people and the community (10,14) . Given this, it is expected that it will bring a significant contribution to the integral care and humanization of care (16) .
Faced with the publications about the home visit in the process of teaching and learning of students during undergraduate courses in the area of health, it was noted the absence of evaluation of the teacher/ preceptor, that is, what is the view of these supervisors in practice educational? What are the real contributions of teaching home visits and its meanings in the construction of knowledge, skills, and attitudes of undergraduate health students from the perspective of teachers /receptors?
Regarding the period that these students were attending, there were students at the beginning of the course, in the first two years, performing the practice linked to the subject and at the end of the course, in the last semesters, in the curricular internship. In a study carried out by first-year medical students, it was found that, before to home visits, they placed expectations on this activity, focusing on their curative role, on the difficulty of communicating with families and on the negative view of the situations they would have during this practice, seeing poverty as synonymous with ignorance, filth, hostility and violence (11) . They also showed difficulty in thinking that they could be well received and establish a rich exchange of knowledge and experience. In a study carried out by the students of the last period of physical therapy, who had already completed the final stage in primary care, students emphasized that a home visit is a propitious tool in the construction of skills and competencies necessary for health work, and after being internalized, it could be taken to other levels of care (13)(14) .
Currently, the traditional means of education alone are not enough, necessitating changes and new resources capable of contributing to the educational area, especially for health education, in which there is a need to reconcile theory and practice (12,15) .
The pedagogical resources that simulate or reflect on reality are indispensable tools to assist in the preparation of the students for the insertion in real scenarios. Sociodrama is a method of teaching. This technique was born from the need to create a psychodramatic approach that focused the groups of students, allowing the identification of internal conflicts, so that, from their understanding, they could be solved. Thus, the true subject of the socio-drama was the group, not each participant, with no spectators and actors, but subjects who participate as protagonists of the scene, as a collective patient. Psychodrama assisted the students in overcoming end-of-course stress and in raising humanized alternatives in their future professional practice. Also, it stimulated learning, allowing the development of more dynamic courses, enriching the role of the teacher and providing the student with an interesting strategy for acquiring knowledge (15) .
With this, the home visit and the approach to the environment where people live are understood as an instrument that facilitates a more reliable view of reality. It has become possible to learn that the human being is formed of multiple dimensions and not only reducing to the biological part or fragmenting in parts, as usually happens in more specialized levels of care (13)(14) .
Most professions in the Health Sciences area seek skills and professional abilities specific to the profession and must be affected by the national health system in force, work in multi-professional health team and integral care (17) . Thus, the home visit can favor the teaching of attitudinal competence and skills for the reception and humanization of health care for individuals, families and the community, and to the biological conception of the human being (18) .
One of the potentials of home visiting education is that it would be a promoter of experiences with people and the world around them, giving the academic the opportunity to develop a broad vision of health, giving them autonomy and allowing the reconstruction of ideas available in any other situation where it is necessary. It also brings a value that implies the relationships and knowledge between professionals and patients, the recognition, respect and appreciation of the diversities and singularities, bringing them closer to the environment where people live, being a tool that facilitates a more reliable view of the reality (13) .
The visit to the scenario of the world lived by the subject enables more flexible and less formal rules than the practices in the institutional scenario. The visit favors the climate of trust and strengthens the human interaction aspect, as well as facilitating the identification of family difficulties and the recognition of the resources available to face it (9) .
Most of the academics who performed practices in primary care at home visit considered it beneficial to know the reality of the population visited, noting the differences of their reality or the one perceived by them in the office. Thus, they were judged more sensitive to the needs and difficulties of the population, which facilitated the understanding of the patients´ lifestyle and improved the doctor-patient relationship (13) .
The study highlighted the weaknesses of the home visit due to the lack of preparation of the students in the initial series to deal with the disease since the students have little professional experience (11) . Failure to comply with home visit planning by students was also revealed, causing disappointment to the patients. In this context, it is indispensable for the student to carry out the visit that the student has an itinerary of information that he intends to obtain and this itinerary must be in harmony with the objectives of the visit to preserve the quality of this activity, respecting the time and the services (9) .
Thus, the home visit should not be set up on an excursion, implying that they should not take all the staff in the person´s home, only those professionals involved in the care. This also requires the preparation of the view, the search for information in the family file that will be visited (9) .
Despite this, unforeseen events may occur in the act of the home visit, and the student must adjust to the conditions found in the home. For this reason, the ethical stance in facing the space of the other is fundamental. Thus, ethics is one of the main foundations for the accomplishment of this pedagogical activity (9) .
During the study, one of the major limitations was the scarce material found in literature searches, showing how insufficient the number of scientific publications on the subject of home visits is, such as a tool for the teaching of university students in the health area, hindering the evaluation and estimation of this resource in the teaching-learning process.

Conclusion
The importance of home visits as an educational strategy for the teaching and learning process of university students in the area of collective health is recognized since the potentialities are noticeably greater than the weaknesses found in the studies.
In the case of the home visiting activity as an important tool to approach the individual, the family, and the community, in the field of collective health knowledge, the main teaching strategy was the early insertion of university students for the direct monitoring of families, contributing to the strengthening of teaching-service-community integration.