NURSE HOME VISITATION PROGRAM

Guide to Effective Programs
for Children and Youth

NURSE-FAMILY PARTNERSHIP

OVERVIEW

The Nurse-Family Partnership is a home visiting-based program to promote the well-being of first-time, low-income mothers and their children. Services such as home visiting by trained nurses, referrals to community resources, and the development of within-family resources are provided through the child's second birthday. Experimental evaluations indicate that participation in NFP has positively impacted poor, unmarried mothers' outcomes (e.g., employment, life skills, problem behaviors, reproduction, parenting), and their sons' and daughters' outcomes as children (e.g., health, social/emotional, language, and cognitive development) or years later as teenagers (e.g., criminal/behavior problems, sexual activity, substance use). Participants who were not poor and unmarried also experienced certain positive outcomes (as described below); however, these impacts were not as diverse or significant as those experienced by the poor/unmarried subgroup. Furthermore, research suggests that NFP produces more significant positive outcomes when implemented by nurses than by paraprofessionals.

DESCRIPTION OF PROGRAM

Target population: First-time low-income mothers and their families; especially women under age 19

The Nurse-Family Partnership (NFP)-formerly known as the Nurse Home Visitation Program-is a program designed to improve the well-being of first time low-income mothers and their children. Specifically, the program is designed to (a) improve pregnancy outcomes by helping women alter health-related behaviors such as smoking, alcohol consumption, and drug use, (b) improve child health and development by teaching parents how to provide more responsible and competent care, and (c) improve families' economic self-sufficiency by helping parents plan for future pregnancies, further their education, and secure employment. The program focuses on small, achievable goals that can be accomplished between nurse visits. Program components (detailed below) are provided through the child's second birthday and include home visits by trained nurses, which begin during pregnancy; referrals to community resources; helping the mother develop within-family resources for the care of her child; and supervision of visiting nurses by a NFP nurse supervisor.

The basic approach of Nurse-Family Partnership is home visits by nurses, which begin during pregnancy. The nurse encourages the mother to change behaviors, such as smoking, poor nutrition and drinking, which may lead to poor pregnancy outcomes. She also educates the mother in how to recognize signs of pregnancy complications and helps the mother build supportive relationships with family and friends. After the child is born, she helps the parents provide better care (i.e., observing signs of illness and interacting with the child in cognitively stimulating ways) and plan future pregnancies. She encourages parents to continue their education and find work. In addition, the nurse links the family with other health and human services.

Nurse-Family Partnership was established as a research demonstration project in Elmira, N.Y. by David Olds and colleagues. The program has expanded to serve between 9,000 and 10,000 thousand families in 23 different states annually (per Peggy Hill, Deputy Director, National Center for Children, Families and Communities at the University of Colorado). NFP is operated out of the National Center for Children, Families and Communities at the University of Colorado. Staff from the Center provide guidance to communities looking to implement Nurse-Family Partnership.

Component	Provided by	Duration	Description
Home visits	Nurses (who work for the department of health, visiting nurse associations, or hospitals) Nurses are trained in a 2-week course and carry a caseload of no more than 25 families.	Visits begin during the second trimester of pregnancy and continue through to 2 years following birth.Visits typically occur weekly to monthly and last 75 to 90 minutes.	A nurse home visitor is assigned to the family and works with that family for the duration of the program. Nurses help parents address three areas: improvement of the mother's development, the care the parents provide their child, and the family's pregnancy planning, educational achievement, and participation in the workforce. Nurses provide a comprehensive educational program designed to help parents provide better care for their child. Nurses also help parents clarify goals, develop problem-solving skills, and develop support systems of family and friends who may be able to help them care for their child.
Resource referral	Nurses	Throughout the program	The nurses help parents connect with various community resources as well as involve other family members in caring for the child.
Nursing supervision	Nurse supervisor	Throughout the program	The nurse supervisor provides guidance to visiting nurses and oversees program implementation. He/she organizes individual supervisory conferences as well as weekly group conferences as well.

Costs:
Average annual cost to implement NFP is roughly $3,000 per family, with higher costs during the initial two years of the program.

EVALUATION(S) OF PROGRAM

Olds, D., Henderson, C., Cole, R., Eckenrode, J., Kitzman, H., & Luckey, D. (1998). Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow up of a randomized trial. Journal of the American Medical Association, 280(14), 1238-1244.

Olds, D.L., Henderson, C.R., Kitzman, H.J., Eckenrode, J.J., Cole, R.E. & Tatelbaum, R.C. (1999). Prenatal and infancy home visitation by nurses: Recent findings. Future of Children, 9(1), 44-65.

Olds, D.L., Henderson, C.R., Tatelbaum, R., & Chamberlin, R. (1988). Improving the life-course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. American Journal of Public Health, 78(11), 1436-1445.

Evaluated population: 400 women from Elmira, New York. Pregnant women were recruited through their sources of prenatal care. To be eligible, they had no previous births, were at less than 26 weeks of gestation and had at least one of the following risk factors: under age 19, single parent or low socioeconomic status. Four hundred women were enrolled in the study, and 89 percent were white.

Approach: The women were randomly assigned to one of four groups: (1) screenings for children at 12 and 24 months; (2) screenings for children at 12 and 24 months and free transportation for prenatal and well-child care through 24 months; (3) the same services, plus home visits by nurses during pregnancy; and (4) the same services, with home visits continuing until the child's second birthday. Because groups one and two made the same use of prenatal and well-child care, they were combined into a single comparison group. Assessments of outcomes included interviews, home observations and reviews of medical and social service records through the children's fifteenth birthdays.

Results: Through age 4, nurse-visited children (group four) had fewer trips to the emergency room. Families in group four also had a significantly lower rate of state-verified reports of child abuse and neglect, and these results were found through the 15-year follow-up. By age 4, no overall differences were found in children's mental development, except among children whose mothers smoked during pregnancy. Regarding maternal life course, at the 15-year follow-up, there were no differences for the whole sample. However, in contrast to a similar subsample (that is, a particular subgroup of women within the sample) in the comparison group, poor unmarried women who had been visited during pregnancy and infancy (group four) had fewer subsequent pregnancies and births; a longer time between the births of their first and second children; a shorter time on welfare; a shorter time receiving food stamps; fewer arrests; and fewer behavioral problems resulting from substance use.

Looking at the children when they were 15 years old, although there were no differences for the whole sample, there were several significant findings for the children of poor unmarried women. Children in group four had fewer instances of running away, fewer arrests, fewer convictions, fewer lifetime sex partners and less smoking and alcohol consumption.

There were many significant findings in the Elmira study, in particular for women with the greatest risk (low-income or unmarried women). The results were strongest when nurse visits continued after birth, rather than just occurring during pregnancy.

Kitzman, H., Olds, D.L., Sidora, K., Henderson, C.R., Hanks, C., Cole, R., Luckey, D.W., Bondy, J., Cole, K. & Glazner, J. (2000). Enduring effects of nurse home visitation on maternal life course: A 3-year follow-up of a randomized trial. Journal of the American Medical Association, 283(12), 1983-1989.

Evaluated population: 1,139 women from Memphis, 92 percent of whom were African-American, and 65 percent of whom were age 18 or younger. Women were recruited if they were at less than 29 weeks of gestation, had no previous births and had at least two of the following risks: unmarried, less than 12 years of education or unemployed.

Approach: The Memphis study was designed to look at the impacts of the program in a different population than that in Elmira-primarily African-American in an urban setting. The study began in 1990 and included a sample of 1,139 Participants were randomly assigned to one of four groups: (1) free transportation for prenatal care appointments; (2) free transportation for prenatal care plus developmental screenings and referrals for children at 6, 12 and 24 months; (3) the same services plus home visits during pregnancy, one visit in the hospital after birth, and one visit at home after birth; or (4) the same services plus home visits until the child's second birthday.

Only groups two and four were assessed during the infancy stage of the study. Assessments included interviews, observations of mother-infant interactions, observations of the home environment and reviews of medical and social service records from pregnancy through age 2.

Results: There were no program impacts on birth outcomes, although women visited by nurses during pregnancy were less likely to have pregnancy-induced hypertension. Nurse-visited women had fewer beliefs about rearing their children that are associated with abuse and neglect, and their children had fewer health care encounters in which injuries and ingestions were detected. Nurse-visited women reported fewer second pregnancies and subsequent births. Furthermore, the homes of nurse-visited women were rated as better for child development (although there was no effect on observed teaching behavior by mothers). There were no effects on children's general health and development.

Some of the results were investigated and found to have endured three years later. Nurse-visited women had fewer subsequent pregnancies, longer intervals between the births of their first and second children and fewer months of using AFDC and food stamps (Kitzman et al., 2000).

Korfmacher, J., O'Brien, R., Hiatt, S. & Olds, D. (1999). Differences in program implementation between nurses and paraprofessionals providing home visits during pregnancy and infancy: A randomized trial. American Journal of Public Health, 89(12), 1847-1851.

Olds, D.L., Robinson, J., O'Brien, R., Luckey, D.W., Pettitt, L.M., Henderson, C.R., et al. (2002). Home visiting by paraprofessionals and by nurses: A randomized controlled trial. Pediatrics, 110(3), 486-496.

Evaluated population: 735 pregnant women living in Denver, CO with (a) no previous live births and (b) who either qualified for Medicaid or had no private insurance. The mean participant age was 19.8 years. Forty-five percent were Hispanic, 34 percent white, 16 percent African-American, 4 percent American-Indian and 1 percent Asian.

Approach: The study in Denver was designed to find out whether or not there are differences in the way nurses and paraprofessionals implement the intervention as well as whether resulting outcomes for mothers and their children differ by home visitor-nurses or paraprofessionals. Participants were randomly assigned to one of three groups: (a) developmental screenings and referral services for children at 6, 12, 15, 21 and 24 months; (b) the same screening and referral services, plus paraprofessional home visits during pregnancy and for two years after birth; or (c) screening and referral services plus home visits by nurses during pregnancy and for two years after birth.

Results: This evaluation shows that mothers' outcomes differed according to whether they were in the nurse or paraprofessional groups. In comparison to the control group, a greater number of significant differences were found for the nurse-visited group than for the paraprofessional-visited group. The only statistically significant effect for the paraprofessional-visited group was that mothers with low psychological resources (i.e., mental health, intelligence) scored higher than control mothers with low psychological resources on a measure of mother-infant interaction.

Participants in the nurse-visited group had several significant differences from participants in the control group. Among mothers who smoked, mothers in the nurse-visited group had significantly lower nicotine levels than mothers in the control group between intake and the end of pregnancy (indicating that they smoked less). Nurse-visited mothers were also significantly less likely than control mothers to experience a subsequent birth or pregnancy in the 24 months following delivery. In addition, nurse-visited mothers were employed longer during the second year following delivery than control mothers. With regard to care giving outcomes, nurse-visited mothers scored higher on measures of mother-infant responsive interaction than control mothers. As for child outcomes, children of nurse-visited mothers exhibited significantly less emotional vulnerability to fear stimuli, and less emotional vitality to anger stimuli than children of control mothers. Furthermore, children of nurse-visited mothers with low psychological resources were less likely to have language delays than their control counterparts and more likely to have higher levels of language and mental development.

SOURCES FOR MORE INFORMATION

References:

Kitzman, H., Olds, D.L., Sidora, K., Henderson, C.R., Hanks, C., Cole, R., Luckey, D.W., Bondy, J., Cole, K. & Glazner, J. (2000). Enduring effects of nurse home visitation on maternal life course: A 3-year follow-up of a randomized trial. Journal of the American Medical Association, 283(12), 1983-1989.

Korfmacher, J., O'Brien, R., Hiatt, S. & Olds, D. (1999). Differences in program implementation between nurses and paraprofessionals providing home visits during pregnancy and infancy: A randomized trial. American Journal of Public Health, 89(12), 1847-1851.

Olds, D., Henderson, C., Cole, R., Eckenrode, J., Kitzman, H., & Luckey, D. (1998). Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow up of a randomized trial. Journal of the American Medical Association, 280(14), 1238-1244.

Olds, D.L., Henderson, C.R., Kitzman, H.J., Eckenrode, J.J., Cole, R.E. & Tatelbaum, R.C. (1999). Prenatal and infancy home visitation by nurses: Recent findings. Future of Children, 9(1), 44-65.

Olds, D.L., Henderson, C.R., Tatelbaum, R., & Chamberlin, R. (1988). Improving the life-course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. American Journal of Public Health, 78(11), 1436-1445.

Olds, D.L., Robinson, J., O'Brien, R., Luckey, D.W., Pettitt, L.M., Henderson, C.R., et al. (2002). Home visiting by paraprofessionals and by nurses: A randomized controlled trial. Pediatrics, 110(3), 486-496.

Website: www.nccfc.org

Website: http://www.nursefamilypartnership.org/index.cfm?fuseaction=home

Program also discussed in the following Child Trends publication(s):

Child Trends. (2001). School readiness: Helping communities get children ready for school and schools ready for children (Research brief). Washington, DC: Child Trends.

Hair, E., Ling, T., & Cochran, S. W. (2003). Youth development programs serving educationally disadvantaged youth: A synthesis of experimental evaluations. Washington, DC: Child Trends.

Halle, T., Zaff, J., Calkins, J., & Margie, N. G. (2000). Background for community-level work on school readiness: A review of definitions, assessments, and investment strategies. Part II: Reviewing the literature on contributing factors to school readiness. Washington, DC: Child Trends, Inc.

SUMMARY & CATEGORIZATION

Program categorized in this guide according to the following:

Evaluated participant ages: Young mothers (most under 19), and their young children / Program age ranges in the Guide: Prenatal, 0-5, 15-21, 22-25

Program components: Clinic/provider-based, Home visiting, Parent/family

Measured outcomes: social/emotional, Life skills, Education/cognitive, Physical health, Behavioral problems

Program information last updated 3/15/07