A Brief History of Home Visiting in the United States

In the United States, the origins of home visiting can be traced to several developments in the 1800’s, including the kindergarten, public health nursing and settlement house movements.   Although there were some broad similarities between the three movements, each had a slightly different focus and used different kinds of individuals to deliver services. Original funding sources were primarily philanthropic, with government funding coming later as programs demonstrated efficacy and grew in size and scope.  Because of the philanthropic sources of funding, a great deal of advocacy to improve the health, education, and environmental conditions of individuals within poverty communities was carried out by the programs. Today’s home visiting programs reflect the important influence and emphases of the pioneering work in the 1800’s. The roots of advocacy and interagency collaboration can also be seen in these early programs.

The early kindergarten movement in the United States, begun in the mid-1800’s, was modeled on the play-based early education programs originated by Friedrich Froebel in Germany in 1837.  In the United States, kindergarten programs were typically focused on immigrant populations living in poverty in large cities (Bhavnagri & Krolikowski, 2000). These kindergartens were funded by philanthropic groups and had teachers who taught young children in the mornings and did home visiting in neighborhoods in the afternoons. Home visiting was designed to teach families about child rearing and how to use toys to stimulate learning, and to build community and family relationships. Teachers acted as family advocates with landlords, local stores, and the government. By the 1930’s, demand increased for kindergartens and there was a shift to morning and afternoon kindergarten sessions and the elimination of the home visiting component.

Another early model of home visiting can be found in the origins of public health nursing in America.  Public health nursing was modeled after nurse home visiting programs in England where trained nurses provided health care and social support in specific geographic regions. Florence Nightingale is generally credited as the first person to use the term “health nursing” and to develop and promote training for regional nurses in England (Georgia Dept of Human Resources).  In the United States, community nursing began in the 1870’s with a handful of nurses relying on funding from philanthropies.   Lillian Wald coined the term “public health nurse” and is credited with pioneering public health nursing in the lower east side of Manhattan in the 1890’s (Bekemeier, 2008; Buhler-Wilkerson,1993).  The work was similar to Settlement House efforts and included community activism to address social conditions in impoverished communities.  The public health nursing approach included preventative care and family education until funding shifted from a philanthropic to government base.  Following the funding shift, the philosophical approach changed to that of a medical model focused on obstetrics, well baby care, and health education. For many years, the focus remained on health care with little attention to the social support that is generally included in nurse home visiting programs in Europe. Government funding contributed to a rapid expansion of the public health nursing workforce in the U.S. from the early 1900’s to the 2000’s.

The Settlement House movement began in American in the 1880’s (Adams, 1910; Weiss, 2006). Through this movement, upper class reformers tried to improve the living conditions of the immigrant poor through a broad reach across social and education programs. They attempted to influence the early education of young children, to provide support for families dealing with health and social crises, and to force improvements in environmental conditions such as housing, parks and playgrounds, and trash collection through legislative advocacy and direct service. Settlement House reformers lived and worked in the poverty communities to both better understand the families being served and to model the behaviors and skills that they believed all individuals should possess.  Wealthy women who were part of the Settlement House movement raised funds for day nurseries, advocated for the development of branch libraries, kindergartens, and night classes, taught homemaking and child care skills, provided homeless shelters, and taught English to new immigrants in urban communities.

The Great Depression in the 1930’s had a huge impact on philanthropic organizations, with more than one in three shutting down between 1929 and 1932. The federal government developed a variety of initiatives to assist the millions of citizens who lost their jobs and their homes (Trattner, 1999).  A prosperous period following World War II led to a decline in interest in funding social initiatives, but there was a resurgence in the 1960’s with the federal “War on Poverty” and initiatives such as Head Start and Home Start.  Home visiting programs were funded with a focus on social issues such as poverty and teen parenting, and health issues including the increasing rates of very low birthweight babies due to technological advances in medicine.  Home visiting programs in the 1960’s were often focused on “infant stimulation” intended to reduce intellectual deficits, improve a range of developmental outcomes, and prepare young children for school success.  Many home visiting programs in the 1970’s shifted their focus to include family support with a broader reach towards prevention services aimed at the whole family, harkening back to the days of the Settlement House movement.  These models included attention to access to support services along with promotion of developmentally appropriate parenting practices and parent self-efficacy.

As home visiting programs demonstrated positive outcomes such as reduction in child abuse, recommendations for universal home visiting programs arose in the 1990’s (Krugman, 1993; U.S. Advisory Board on Child Abuse & Neglect, 1991).  Unfortunately, the federal government did not respond to such recommendations, but a wide range of local foundations and state government programs increased their attention and directed funding towards home visiting in poverty communities.  In addition, some state governments provided categorical funding streams for home visiting services aimed at specific populations, such as teen parents and children and families who were part of health and child welfare systems.

Today’s programs may be funded within the mental health, child welfare, early education, physical health, or developmental disability systems or by private foundation dollars focused on one of these systems.  Although linkages and collaborations are essential for effective service delivery, limitations usually exist in the development of seamless systems of care involving all aspects of health and development (Astuto & Allen, 2009; Finello & Poulsen, 2011).  Despite more than 100 years of home visiting services, most programs find themselves battling the same issues as those seen in the 1800’s.  As Gomby and her colleagues (1999) point out, home visiting programs are being asked to solve broad social problems of enormous magnitude while relying upon individual changes in behavior over short periods of time.  Clearly, we need to be more realistic about goals, outcomes, and what should be considered “success” in the delivery of home visiting services to families over a short period of time.

Click here to read more on the current Home Visiting Program

Coming soon:  “Challenges in Delivering Services through Home Visiting Programs”


Submitted by:  Karen Moran Finello, PhD

Karen Moran Finello photo


References & Further Reading

Adams, J. (1910).  Twenty years at Hull House. New York:  Macmillan.

Astuto, J. & Allen, L. (2009). Home visitation and young children: An approach worth investing in?  Society for Research in Child Development, Social Policy Report, XXIII(IV), 3-21.

Bekemeier, B. (2008).  Nurses on the frontlines of community health.   Northwest Public Health, Spring/Summer. University of Washington School of Public Health & Community Medicine. www.nwpublichealth.org/docs/nph/s2008/bekemeier_s2008.pdf

Bhavnagri, N.P. & Krolikowski, S. (2000).  Home-community visits during an era of reform (1870-1920).  Early Childhood Research & Practice, 2(1).  http://ecrp.uiuc.edu/v2n1/bhavnagri.html.

Buhler-Wilkerson, K. (1993). Bringing care to the people: Lillian Wald’s legacy to public health nursing. American Journal of Public Health, 83(December), 1778–1786.

Finello, K.M. & Poulsen, M.K. (2011). Unique System of Care Issues & Challenges in Serving Children under Age 3 and their Families.  Special Issue of American Journal of Community Psychology, 2011,  DOI 10.1007/s10464-011-9458-6.

Georgia Dept. of Human Resources, Div. of Public Health.  The history of public health nursing in Georgia (1898-2002).  http://health.state.ga.us/pdfs/nursing/Hist.Pub.Hlth.Nurse.web.pdf

Gomby, D.S., Culross, P.L. & Behrman, R.E. (1999).  Home visiting:  Recent program evaluations–Analysis and recommendations.  Future of Children, 9(1), 4-26.

Krugman, R. D. (1993).  Universal home visiting:  A recommendation from the U.S. Advisory Board on Child Abuse & Neglect.  Future of Children, 3(3), 184-191.

Trattner, W.I. (1999). From poor law to welfare state. A history of social welfare in America. (6th Ed.). New York:  Free Press.

U.S. Advisory Board on Child Abuse & Neglect.  U.S. Dept. of Health & Human Services (1991).  Creating caring communities: Blueprint for an effective federal policy for child abuse and neglect.  Washington, DC:  U.S. Gov. Printing Office.

Weiss, H. (1993).  Home visits:  Necessary but not sufficient.  Future of Children, 3(3), 113-128.