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A Historical Overview
Friendly visitor, district visitor, homemaker, visiting teacher, visiting nurse, family social worker, home visitor, family physicianâall have provided care and support to families through visits in the home. Professional and lay workers, paid and volunteer, they have brought to families child care information, emotional support, health care, knowledge of community resources, help in learning to cope with everyday problems and, at times, homemaker services. Although such services currently address a variety of family needs, traditionally most home visit programs were prompted by conditions of poverty, illness, or the need for infant and child care.
In this book, home visiting is defined as the process by which a professional or paraprofessional provides help to a family in their own home. This help focuses on social, emotional, cognitive, educational, and/or health needs and often takes place over an extended period of time. Among professional groups in our society, nurses, social workers, and teachers are major providers of home services, although other professionals (including physicians, psychologists, psychiatrists, counselors, physical therapists, and speech therapists) also provide services in the home. Members of religious organizations have a long history of caring for individuals in their own homes. Many paraprofessionals or lay workers provide home-based family support. These individuals often share common characteristics or experiences with the families they visit. Parents, for example, may be recruited to visit other parents. We will use the term home visitor for any of these professional or paraprofessional helpers.
Home visiting may be initiated for a variety of reasons. It may be offered as a universal service to families; for example, a local health center may provide home visiting by nurses to all first-time parents of newborns within its geographic area. Such services could include support and encouragement to the new parents as well as information on nutrition and infant care. Home visiting may be offered as a prevention or intervention procedure prompted by the special needs of children. As a prevention effort, home visiting services may be offered to families whose children are at risk for school failure. As an intervention effort, educational agencies may provide home visiting by teachers to parents of each developmentally delayed child within a school district. In both types of servicesâintervention and preventionâhome visitors could help parents learn ways of enhancing their childâs social and cognitive development. In other instances, families may request services such as help with caring for a physically disabled or chronically ill family member. The judicial system may also require some families to participate in home visits, as in child neglect or abuse cases or child custody disputes.
Structural changes in the family, including a high divorce rate and large numbers of teenage parents and single-parent families, have resulted in an increased number of women and children living in poverty (Zigler & Black, 1989). The problems associated with poverty (e.g., high rates of infant mortality and premature births, child abuse and neglect, drug abuse, high school dropouts) have received increased attention in recent years (Bronfenbrenner, 1987; Moynihan, 1986). Many families face other difficult situations, such as job stress and insecurity, disruptive family relations, few social supports, and chronic illness (Rutter, Champion, Quinton, Maughan, & Pickles, 1995). Numerous social, educational, and health agencies are emphasizing home visiting as an extremely valuable procedure for helping families address these pervasive personal and social concerns.
Home visiting offers many advantages for working with families. It often helps overcome barriers to available services, such as illness, physical disability, lack of transportation or child care, low motivation, or alienation from the educational, social, or medical establishment. As a result, needed services reach many individuals and families who otherwise might not receive help. Home visiting can reduce the need for hospitalization by providing the support necessary for individuals to stay with their families. Home visiting is also influenced by the increased interest in self-care, the lower costs of home care when compared with institutionalization, and the increased willingness of insurance providers to cover the costs of home care (Berg & Helgeson, 1984). Home visiting provides a unique opportunity to obtain relevant information about a familyâs environment, resources, and needs, and it enhances a service providerâs ability to individualize services. Also, by reaching out to people in their own homes, one conveys a message of respect and appreciation of the family needs. Visiting in the home allows the family to be in more familiar surroundings.
Additional advantages of home visiting for families with children stem from several assumptions related to parenting and parent-child interactions. The first assumption is that parents are usually the most consistent and caring people in the lives of their young children. For a majority of parents, bonding and caring for their children begins in infancy and continues throughout childhood, adolescence, and beyond.
A second assumption is that parents can learn positive, effective ways of responding to their children if they are provided with support, knowledge, and skills. Some parents have less access to parenting role models and knowledge about children than do other parents. Helping these parents to acquire knowledge and skills can be done in the home and can have a very positive influence on their childrenâs development.
A third assumption is that for parents to respond most effectively and positively to their children, their own needs must be met. Parents who are out of work, worried about housing or food, or are experiencing emotional problems from events such as divorce or other family stress often find it difficult to care for their children. Through home visiting, one can provide support to parents, help them become more effective in addressing their day-by-day concerns, and help them with parenting competencies.
In this chapter, we will trace the history of home visiting, from its early beginnings to the present, in order to place in perspective current home visiting practice and to learn from and build on the work of the early leaders in this field. The few existing historical accounts of home visiting generally focus on events within specific professions such as social work, nursing, education, or medicine. Levine and Levine (1970) present a historical account of visiting teachers and social workers, Holbrook (1983) describes the social workerâs role in home visiting, Buhler-Wilkerson (1985) describes the history of public health nursing, and Donahue (1985) presents a comprehensive view of the historical antecedents of todayâs nursing profession, including early efforts in home visiting, institutional care, and community care. In this chapter, we will highlight historical developments across different professions and with diverse populations to provide the reader with an understanding of the rich heritage shared by those who engage in home-based services.
History of Home Visiting
It is difficult to date the beginning of formal home visiting because caring for those in need has traditionally been a responsibility assumed by relatives, friends, and neighbors, with societal efforts developing gradually when informal support was not adequate. Although home visiting is often noted as developing during the past two centuries, organized visits to the sick in their own homes were occurring as early as 200 and 300 A.D. During this time, early Christian religious groups, as part of their charitable works of mercy, reached out to the sick by going to their homes (Donahue, 1985). Within this religious tradition, changes occurred over the centuries as care sometimes became more prevalent in institutions and sometimes in homes, often determined by sanitary conditions in institutions (Donahue, 1985; OâSullivan, 1982). These religious groups have continued to be a strong presence in visiting the sick at home.
Formal home care was also prevalent in Elizabethan England when services were provided to paupers in their homes (Fink, Wilson, & Conover, 1963). These services were known as âoutdoor reliefâ because they were provided outside rather than inside institutions. This practice of providing care at home was adopted in colonial America as the dominant method of public care for poor children and their families. By the 19th century, a shift in philosophy occurred and institutional care came to be considered superior to home care for poor children. When families could not provide for them, neglected them, or left them orphaned, children were taken from their homes and placed in almshouses (Fink et al., 1963). This practice was also true in England, where widows were not provided support in their homes; rather, their children were sent to alms houses where hundreds of children often resided. The state of New York built almshouses in every county to house and educate poor children. By the mid-19th century, almshouses had been established in all major seaboard cities (Moroney, 1987). Such efforts were not without strong critics who described the negative effects of these arrangements in breaking up families rather than keeping them together (Bremner, 1971). As a result, during the 19th century, some states continued home care, and the state of New York began to shift its emphasis to home care.
While these changes were occurring, the foundation was being laid for the provision of home care by trained home visitors. Florence Nightingale, through her efforts on the part of the sick poor, was a pioneer in this field. Her first public comments on home visiting appeared in a letter to William Rothbone in November 1861 (Monteiro, 1985). Rothbone, a member of the District Provident Society in Liverpool, had employed a nurse to care for the sick in his geographic district (Richmond, 1917). When Rothbone tried to expand these services to other districts, he could not find trained nurses, so he turned to Nightingale for support. She recommended that nurses be specifically trained for his project and proposed a plan for the training and employment of women in hospital, district, and private nursing. Following her advice, Rothbone opened a training school in Liverpool the following year.
Nightingaleâs concern with the sick, especially those who were poor, continued throughout her life. She linked the importance of home care with nursing care. In 1867 she wrote, ânever think that you have done anything effectual in nursing in London till you nurse, not only the sick poor in workhouses, but those at homeâ (cited in Monteiro, 1985, p. 181). Although one of the major themes of her writings was the need for adequate training of nurses, she also called for rural health missioners, or nonnurse health visitors, to provide hygiene instruction for mothers living in rural towns and villages (Nightingale, 1894). Her final reports on district nursing and home care overlapped with an era of major social and cultural changes in America, from the 1890s to the time of the First World War.
Nightingaleâs efforts in England were predated by a religious order in France, the Congregation of Bon Secours. In 1824, in a departure from what had then become the norm of providing institutional care, the women of this order began to care for the sick in their own homes. This religious order expanded to Ireland in 1861 and to England in 1870. In 1881, they went to Baltimore, Maryland, where they began to address, through home visiting, the prevalence of disease, poverty, and unsanitary living conditions, conditions also being experienced by families in other large American cities at this time (OâSullivan, 1982).
The Expansion of Home Visiting in America
Since the late 19th century, a number of circumstances contributed to organized formal efforts in the United States to help those in need. An increasing number of poor people living in urban settings, especially those who were sick, could not afford institutional care and needed support in the home. To assist those who were visiting the poor, in 1883, the Charity Organization Society of New York City published a handbook for visitors. The organizationâs purpose was to coordinate philanthropic resources. This work emulated the charity organization movement begun in London in 1869 that used volunteers to âvisit, counsel, and instruct the poorâ (Bremner, 1971, p. 52).
At the turn of the 20th century, when immigration was combined with continuing urbanization, further increases occurred in the number of urban poor, and a corresponding increase occurred in the social conditions associated with poverty (Levine & Levine, 1970). These demographic changes influenced the development of the visiting nurse, visiting teacher, public health nurse, and social worker. Many new child and family services were developed to address the conditions associated with urbanization and immigration, especially poverty, contagious diseases, unhealthy living conditions, high infant mortality, school dropouts, and delinquency. During this time, the helping professions were all strongly influenced by the philosophical view that environmental conditions were major contributors to personal problems and illness. Consequently, intensive efforts were directed at changing poor social conditions, particularly those contributing to illness, accidents, infant mortality, and school problems.
The role of the visiting nurse continued to expand, and two additional roles for service were developed: visiting teachers and social workers. These professions have strong roots in the settlement house movement in New York, Boston, Philadelphia, and Chicago. Settlement houses were established in communities with high levels of poverty. The settlement house workers, typically well-educated, upper-class women, served to improve social conditions and provide support for individual families (Addams, 1935).
In the early 1900s, visiting school teachers began working in the major urban cities of the United States. The visiting teacher was developed as a liaison between the school and the home because workers in the settlement houses saw the need to improve educational conditions for children by working with the childrenâs teacher. These visiting teachers, forerunners of the school social worker, worked with families when children showed academic difficulties or were truant or incorrigible, or when there were adverse home conditions (Levine & Levine, 1970). When the visiting teacher began her work, she used an ecological approach, becoming familiar with the neighborhood, the attitudes of the people toward education, the settings in which people worked and lived, recreational opportunities, school programs, and services of public and private agencies. By being in the community, the visiting teacher came to know the family and child and could use her relationships with the schools to help the family and school work together. Classroom teachers also benefited from the input of the visiting teachers because they often received information about the childâs family that made it easier to understand the child and provide attention to any special needs. As a result of these positive home-school experiences, âa resident in each of the settlement houses took on the special assignment of calling on the families of children who presented special problems of an educational, social or medical natureâ (Levine & Levine, 1970, p. 128).
The sociocultural events that influenced the development of home services by teachers also strongly influenced the initiation of the field of social work. In the preface to her classic book, Friendly Visiting Among the Poor, Richmond (1899) acknowledged the influence of the associated charities that had organized Bostonâs friendly visitors almost two decades earlier. Addamsâs (1935) work at Hull House in Chicago was also a significant event in the development of social services. Although social work history and tradition have been intricately woven with home visiting, Holbrook (1983) observed that home visiting has not been addressed by most social work historians.
Providing mental health services in the home setting is usually associated with the beginning of social work. Early social workers focused on helping individuals and reforming societyâs institutions. Holbrook (1983) noted that social work developed during the Progressive Era of the early 1900s as a reaction to the survival-of-the-fittest advocates and the Social Darwinism philosophy of the late 19th century. Rather than promoting those philosophies, social workers tried to protect individuals from social and natural deprivation (Hollis & Wood, 1981). During this time, the child-saving movement was born to save the children of the working a...
