Reflections on Home Visiting
By Phyllis J. Sloyer, RN, PhD, FAHM, FAAP
The appropriated dollars for home visiting are probably the largest increase the Title V program has received since its inception. It is remarkable that very little attention was given to it as national health reform legislation moved to a final bill for signature by President Obama. While novices may think this is a strong statement about preventive health services and early intervention services for young children, it is in fact another evolution of home visiting since the formation of the United States. I expect that you will learn a lot about this initiative in this issue of Pulse. Therefore, I am not going to reiterate the provisions of the legislation, but rather trace the origins of home visiting so that you recognize the cyclical and incremental nature of public policy. I am especially grateful to the Minnesota Department of Health for an outstanding summary of the history of home visiting legislation.
Home visiting began in the colonial history of the United States to take care of the poor at home and was strongly influenced by our British ancestors and the legacy of providing help to orphaned or neglected children. We can’t forget Florence Nightingale’s legacy of training nurses in home care skills. In the mid 1800s the nurses were known as district or friendly visitors. The Mary Ellen Wilson story in 1874 changed the course of child abuse prevention and intervention services to children. Mary Ellen was an 8-year-old child abused by her adoptive parents. It is also interesting that until 1874, our nation had a Society for the Prevention of Cruelty to Animals, but not for children. As we leave the 19th century, we enter the Progressive Era and the beginning of the family support movement stimulated, in part, by immigration, poverty, urbanization and other social and environmental issues.
At the dawn of the 20th century, public policy promoted an increase in a variety of home visitors, representing education, nursing, social services, and churches. President Theodore Roosevelt conducted the First White House Conference on Children and laws were created that recognized the home as the best place for serving families. Now we jump forward to 1935 and the enactment of the Social Security Act, specifically Title V. The federal law created programs for women and children, including handicapped children. Later, we learn that Title V had specific language in it relating to home visiting.
Historians note that the modern home visiting programs began as part of the War on Poverty in the 1960s. Notably, early childhood and child development research provided the evidence that the first five years of life were the formative and critical years of intellectual development. Home visiting was focused on supporting family and child development. These programs continued through the 1960s and 1970s through maternal and child health programs, Head Start and other models that brought family support programs to homes. In the mid 1970s, two landmark pieces of federal legislation offered other opportunities for home visiting: Child Abuse and Prevention Treatment Act and the Education of All Handicapped Children Act. Both of these bills offered funds for home visiting services.
In the latter part of the 20th century, Healthy Start was added to Title V of the Social Security Act in recognition of the need to reduce infant mortality and promote early entry into prenatal care. Many Healthy Start programs offered home visiting as a service approach to meet their objectives. In this issue of Pulse you will read about evidence-based models and best practices used to achieve several objectives relating to the reduction of infant mortality, child abuse or delayed growth and development.
Needless to say, throughout history our nation has used home visiting as a strategy to support families and improve the health and development of young children. Home visiting has had a home in multiple agencies and certain practices have been proven to be effective. At the dawn of the 21st century, we witness landmark national health reform legislation and it should be of no surprise to anyone that home visiting is a part of the legislation, given its origins and emphasis on young children and families. However, it is not a service to be owned by any one agency, but rather a service that begs for collaboration, careful planning, effective strategies and is subject to sound performance measures. At the end of the day, all that matters is how we support and strengthen future generations.