Strengthening Home Visiting To Promote the Health and Well-Being of Indigenous Families
This article contains a correction.
The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, through home-based services, works to improve maternal and child health, support positive early development and learning, and generally strengthen families’ health and security. The program has demonstrated effectiveness for families and has earned bipartisan support—but it needs to be reauthorized in order to reach more families and continue to benefit communities. Lawmakers have the opportunity to reauthorize it through the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act of 2022. This law would increase investment in MIECHV, institute changes to help relieve the program’s administrative burdens, and better monitor its positive outcomes.
One important aspect of the proposed reauthorization pertains to a part of MIECHV that is often overlooked—Tribal MIECHV, which is funded by a specific set-aside from the larger MIECHV program for American Indian and Alaska Native (AI/AN) children and families. Unfortunately, the Tribal MIECHV program currently only reaches 3.8 percent of Tribal entities and 0.7 percent of eligible AI/AN children. The proposed reauthorization would double the set-aside for the Tribal MIECHV program from 3 percent to 6 percent, totaling approximately $186 million in grant funding through 2027. This would play a critical role in expanding families’ access to Tribal MIECHV, and moving forward, reauthorization would help set the stage for additional reforms to strengthen it. With MIECHV, and therefore the set-aside dedicated to supporting Tribal communities, facing a vote in Congress, legislators must seize this opportunity to promote the health and well-being of Indigenous families.
Historical inequities set the stage for current health disparities
With the reauthorization of MIECHV, Congress faces an opportunity to address historical policy decisions that have led to inequities in access to health care in AI/AN communities. For hundreds of years, Indigenous families faced colonization, genocide, and forced assimilation, and they still must contend with ongoing racism and attacks on their cultures, communities, and sovereignty. In short, AI/AN families have long been subject to deep and pervasive inequities. Native American children and communities feel this legacy most acutely in high rates of poverty, food insecurity, health disparities, and racial and gender wage gaps. Moreover, recent challenges such as the infant formula shortage and the COVID-19 pandemic have laid bare the many shortcomings in the United States’ health care system and economy. As just one example, COVID-19 resulted in a seven-year drop in life expectancy among Native American communities. This drop has no modern parallel. In addition, younger people in Native American communities experienced among the highest COVID-19 death rates in the nation.
Home visiting interventions, while not a cure-all, are a critical part of addressing some of these health disparities. In fact, Tribal grantees who participated in home visiting programs from fiscal year 2012 through fiscal year 2014 saw improvements in maternal and newborn health (62 percent); school readiness and achievement (69 percent); family economic self-sufficiency (77 percent); and coordination and referrals (69 percent). Moreover, 85 percent of grantees saw decreases in child injuries; abuse, neglect, or maltreatment; and emergency department visits, and 77 percent saw decreases in reported crime or domestic violence.
A Strong Start in Life: How Public Health Policies Affect the Well-Being of Pregnancies and Families
AI/AN mothers face unique challenges
Even prior to the pandemic, AI/AN mothers experienced significantly higher rates of maternal mortality and birth complications than white women. Systemic barriers to receiving maternal health care, high rates of poverty and food insecurity, the trauma of racial weathering, and distrust in institutional care providers resulting from a history of forced separation contribute to poorer outcomes for AI/AN mothers and drive inequities in maternal and infant health. Moreover, more than 80 percent of AI/AN women have experienced violence, including psychological aggression and intimate partner violence (IPV), in their lifetimes. Women, on average, also higher risk of IPV during pregnancy, which compromises maternal health and the well-being of their developing infants. These unique challenges pervade AI/AN communities and contribute to longstanding inequities in maternal and infant health. And they are complicated by the fact that due to comparatively smaller population numbers, AI/AN communities are often excluded from statistical estimates of health across a range of issues.
American Indian and Alaska Native Maternal and Infant Mortality: Challenges and Opportunities
Home visiting services can be a lifeline to thousands of families with young children—and among Tribal communities, the need for direct support is even greater. Through reauthorization and expanded funding, Congress has an opportunity to make critical reforms to Tribal MIECHV, including culturally responsive data collection and program modernization. Such reforms would ensure that the program meets the need of more Tribal entities and improves the provision of support services.
Reauthorization and expanded funding
To institute programmatic reforms such as improving program effectiveness and data collection efforts and modernizing program administration, Congress must reauthorize Tribal MIECHV. Since MIECHV funding is mandatory, the proposed Walorski legislation both reauthorizes and appropriates funds at increasing intervals for a term of five years, while also doubling the Tribal MIECHV set-aside. Adequate federal investments in Tribal MIECHV are needed to fulfill the promise and responsibility of the federal government to support underserved Indigenous communities and advance racial equity. Congress therefore has a critical opportunity through this bipartisan legislation to secure five-year guaranteed funding for a program with outsize benefits to its recipients.*
One major change in the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act involves reducing administrative costs and burdens and streamlining reporting requirements that could enable the home visiting workforce to dedicate more of its efforts to connecting with eligible families and administering services. The legislation aims to reduce the number of hours agencies and home visiting staff spend complying with federal paperwork by at least 15 percent. Additionally, new efforts to expand the MIECHV program should involve reducing barriers to new Tribal grantees seeking eligibility for service grants. In 2021, the Bipartisan Policy Center suggested that an increase of at least $50 million in funding would expand the program to at least 100 Tribal entities. Entities could also use this funding to leverage intermediaries to help more families get connected to these services.
Robust data collection
While MIECHV overall has proven benefits for children, parents, and the economy, there is limited evidence on the effectiveness of home visiting in Tribal settings due to ongoing issues with data collection and research capacity within the Tribal MIECHV program. For instance, not all families served through the Tribal MIECHV program are of Indigenous heritage and data collection is not disaggregated to show the program’s specific impacts on Tribal populations. Thus, it is unclear how much of an impact this program has on solely Indigenous communities. Additionally, current data collection methods may not reflect a respect for Tribal sovereignty, self-determination, or cultural practices.
Evaluating the effectiveness of the Tribal MIECHV program
While MIECHV overall has proved effective, there is limited evidence on the effectiveness of home visiting in Tribal settings. Thus, Tribal grantees have often had to adopt existing home visiting service models, such as Parents as Teachers (PAT), Nurse-Family Partnership (NFP), and the Parent-Child Assistance Program (PCAP), that have shown evidence of effectiveness among other vulnerable communities. Based on the limited scope of available data, Family Spirit, the only model designed specifically for Indigenous communities, is currently also the only service model that meets Department of Health and Human Services criteria for evidence-based programming specifically for Tribal populations, demonstrating improvements in positive parenting practices and behavioral improvements in children. Adopting more culturally inclusive data collection practices and disaggregating samples to examine the specific impacts of other home visiting models on Tribal families will be critical to expanding the evidence base around the effectiveness of home visiting in improving Indigenous life outcomes.
Several efforts to fill current gaps in research and data collection, including the Multisite Implementation Evaluation of Tribal Home Visiting (MUSE) project, the Black Maternal Health Momnibus Act, and the Walorski legislation, propose improving state-Tribal partnerships in the implementation of home visiting services; increasing research and data collection on maternal morbidity and mortality; and developing an annually updated, publicly available website that reports certain information regarding individual and family outcomes on a state or territory basis. These efforts—as well as taking steps to include Indigenous people in data collection efforts, increase transparency in information about study intentions and outcomes, and respect Indigenous cultural traditions—are critical to improving data collection practices among AI/AN communities.
Home visiting programs have consistently struggled to recruit and retain service providers, citing as challenges to the remaining workforce their workload, including excessive paperwork; inadequate training; difficulty providing services to clients, particularly in rural areas; low pay; and lack of opportunity for advancement. Increasing salaries and employee benefits, enhancing supervisor support, providing more training and professional development, and ensuring greater collaboration with community organizations are all necessary measures to increase job satisfaction and decrease burnout among workers. To provide workforce support for home visitors who serve Tribal populations, programs must also invest more in local intermediaries, including local leadership and community-based outreach organizations, with cultural and linguistic knowledge that reflects the communities they serve.
The COVID-19 pandemic spurred innovations in data, technology, and service delivery as workarounds for the inability to conduct many home visiting services in person. In order to become more responsive to current challenges and family needs, the Tribal MIECHV program should continue to build upon existing and new strategies to administer services, such as meeting with families outside the home; delivering health and safety or curricular items, such as masks, hand sanitizer, and educational materials, to families for use during visits; and providing virtual home visits. To build on these innovations, further federal investment in the Tribal MIECHV program is needed to help close the digital divide—evidenced by the 17 percent of 3- to 18-year-old AI/AN children who did not have home internet access in 2019—and enable Indigenous families’ greater access to virtual home visiting services. An increase in funding through the proposed Walorski legislation would help facilitate the allocation of technology and technology tutorial resources to both families and providers.
In 2021, the Biden administration released an executive order on advancing equity and support for underserved populations through federal policymaking and investments. Promoting the health and economic well-being of Indigenous families through the expansion of the Tribal MIECHV program is one critical step toward fulfilling that promise. Home visiting services promote healthy child development, school readiness, and positive parenting practices; improve parents’ educational and vocational outcomes; and connect families to necessary legal, cultural, health care, child care, early learning, and crisis planning resources. For Indigenous families in dire need of support, federal commitments to fund and modernize Tribal MIECHV may serve as a critical avenue for promoting Indigenous families’ health and well-being. Congress has a critical opportunity to reauthorize MIECHV through the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act and ensure that the promise of Tribal MIECHV is realized for all Indigenous families and communities.
Authors’ note: This article mostly uses the census-defined term “American Indian and Alaska Native (AI/AN)” in keeping with the materials cited in this article. The authors also use the terms “Indigenous,” “AI/AN,” and “Native American” interchangeably as is consistent with the conventions through which these communities may refer to themselves. CAP style capitalizes “Indigenous” and “Tribal.”
The authors would like to thank Maggie Jo Buchanan, Madeline Shepherd, Mariam Rashid, Arohi Pathak, and Mara Rudman for their support and guidance in the development of this work.
* Correction, December 8, 2022: This article has been updated to accurately reflect the mandatory funding structure of MIECHV, including Tribal MIECHV, noting that it is not subject to the annual appropriations process.
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Intern, Early Childhood Policy
Senior Policy Analyst