NURSE-FAMILY PARTNERSHIP

OVERVIEW

The Nurse-Family Partnership (NFP) is a home visiting-based program intended to promote the well-being of first-time, low-income mothers and their children.  Services such as home visiting by trained nurses to provide parenting education, referrals to community resources, and the development of within-family resources are provided through the child’s second birthday. 

Experimental evaluations from three very different communities (Elmira, NY; Memphis and Denver) have looked at a variety of maternal and child outcomes, including behaviors during pregnancy (e.g., use of services, health behaviors), birth outcomes, parenting behaviors, and subsequent pregnancies.  Participation in NFP has positively impacted mothers during pregnancy (e.g., nutrition, use of WIC, number of cigarettes smoked) and the home environment (e.g., the number of hazards observed in the home, frequency of punishment, behaviors that stimulate language skills, and the number of stimulating toys). Mothers who received nurse home visits also reported fewer subsequent pregnancies and a longer time between pregnancies. Several impacts for the child have been positive, such as arrests at age 19.

Given the large number of studies and the many outcomes examined, overall, varied impacts have been mixed, with positive impacts for some subgroups and no observed impacts (and in very few instances, negative impacts) for other subgroups of mothers. and their children (e.g. child’s IQ, number of times child ran away or was stopped by the police). Some evaluations have also shown positive impacts at certain points in the children’s lives and no impacts on the same outcomes at other points.

Participants with fewer economic, social and emotional resources have shown more positive impacts than those with more resources. The children of low-income, unmarried mothers had fewer behavioral problems. In addition, subgroup positive impacts have been found for birthweight and preterm birth for mothers under 17 and those who reported smoking five or more cigarettes a day during pregnancy. Children who were born to mothers with low psychological resources in the nurse-visited group had higher levels of language development and higher mental development. When mothers’ had low psychological resources, children in the nurse-visited condition had more supportive home environments, more developed language, better executive functioning, and less negative researcher-rated behavior.

DESCRIPTION OF PROGRAM

Target population: First-time low-income mothers in their first or second trimester of pregnancy 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.

The program has several underlying assumptions that determine the target population and approach. First, a woman’s first pregnancy provides the best chance to promote and teach positive health and development behaviors. Second, a trusting relationship between the mother and nurse focused on the mother’s self-efficacy is critical to achieving the program’s goals. Third, the relationship must last long enough to ensure that the nurse and mother have time to address critical parenting and health behaviors.

Program components are provided through the child’s second birthday and include home visits by trained nurses, referrals to community resources, and supervision of visiting nurses by an NFP nurse supervisor. Home visits by nurses begin during pregnancy.  During these visits, the nurse encourages the mother to change behaviors which may lead to poor pregnancy outcomes such as smoking, poor nutrition and drinking.  The nurse also educates the mother on how to recognize signs of pregnancy complications and helps the mother build supportive relationships with family and friends.  After the child is born, the nurse helps the parents provide better care (i.e., by observing signs of illness and interacting with the child in cognitively stimulating ways) and plan for potential future pregnancies.  Last, the nurse links the family with other health services they may need and encourages the parents to continue their education and find work.

The Nurse-Family Partnership was established in 1977 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 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.

EVALUATION(S) OF PROGRAM

Olds, D. L., Henderson Jr., 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: Women (N=354) from a small, semi-rural Appalachian region of New York State were evaluated, and they were pregnant with what would be their first child.  Program staff specifically targeted mothers who were under 19, unmarried, or from a low SES family, and less than 25 weeks pregnant; however, they allowed women without any of these characteristics (roughly 15% of the participant group) to enroll as long as they were first-time mothers.

Approach: Women were enrolled in the program in the first 30 weeks of pregnancy.  Program evaluators randomly assigned women to one of four groups: two control groups, one providing a developmental screener and the other providing a developmental screener as well as free transportation to prenatal and well-child visits; and two nurse-visiting groups, one that provided visits only during pregnancy (pregnancy group) and one that provided visits during and up to two years of the child’s life (pregnancy/infancy group). The two control groups were combined into one (165 women), and the two nurse-visited groups were combined into one as well (189 women). Interviews of the women were conducted at the time of registration for the program and again at the 6th, 10th, 22nd, and 46th months of the children’s lives.  Records from county departments of social services were also used for data. Nonwhites were excluded from the analyses. Also, the four treatment groups were collapsed into two, because there were no significant differences at baseline between the screened and transportation groups, and there were no significant differences at baseline between the two home-visited groups, hereafter referred to as the pregnancy/infancy group.

Results: Overall, the effects of the program were stronger for women in the pregnancy/infancy group than for those in the pregnancy group.

 At the six-month interview, 59 percent of the pregnancy/infancy group and 27 percent of the control group had graduated from or enrolled in an educational program.  This difference was statistically significant (p < 0.05).  At the 10-month interview, the program no longer had an impact that reached significance, but a significantly higher percentage of unmarried women receiving the intervention graduated from or enrolled in an educational program, compared with the control group.  Among unmarried women, 60 percent of the pregnancy/infancy group and 31 percent of the control group had graduated from school or enrolled in an educational program.  At the 22-month and 46-month interviews there were no differences among the three groups.  Throughout the follow-ups, there were no education differences between the pregnancy group and the control group.

At the 22-month interview, poor, unmarried younger (fewer than 19 years of age) women in the pregnancy/infancy group had worked 2.5 times longer than poor, unmarried younger  women in the control group.  At the 46-month interview, poor, unmarried women in both experimental groups had worked longer on average than poor, unmarried women in the control group. 

At 10th month of the child’s age, more nurse-visited, poor, unmarried, older (19 years of age or older) women reported that other family members helped more with child care, compared with the control group. At the child’s birth, poor, unmarried, older women were on public assistance for 157 fewer days than the control group. However, this impact faded at 24 months of the child’s age and was nonsignificant.

Poor, unmarried women in the pregnancy/infancy group had a third as many subsequent pregnancies as the control-group, poor, unmarried women at the 22-month follow-up. Poor, unmarried women in the pregnancy/infancy group had an average of .17 subsequent pregnancies, and those in the control group had an average of 0.51 subsequent pregnancies.  At the 46-month interview, women in the three groups were equally as likely to have had subsequent pregnancies.  For poor, unmarried women, however, those in the pregnancy/infancy group were less likely to have had a subsequent pregnancy (0.58 pregnancies) than their counterparts in the control group (1.02 pregnancies).

Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77(1), 16-28.

Evaluated Population: See above study.

Approach: See above for random assignment and exclusion of nonwhites. Treatment groups 1 and 2 were combined for the reasons mentioned above, and groups 3 and 4 were combined because the treatments were identical up until the baby’s birth.

Researchers measured impacts in four major outcome categories: mothers’ use of services; support person behaviors, health habits and obstetrical conditions and birth outcomes. They collected data at intake, at the 32^nd week of pregnancy, and when mothers were admitted to the hospital for their baby’s birth. Some data were also collected when the mothers were in their first and third trimesters of pregnancy and the first and last home visit during the mother’s pregnancy.

The use of services, collected at the 32^nd week of pregnancy and at the baby’s birth, included number of services known, childbirth education, number of nutritional supplementation vouchers, number of antepartum visits, and number of calls to physician or clinic.

The support person behaviors, also collected at 32 weeks gestation and at birth, were the number of talks about problems the mother had with support people, the father’s  interest in the pregnancy and his presence at delivery, and the amount of household help the mother receives.

Some health data were taken at the first and third trimesters: kidney infection, bladder infection, percent of blood made of red blood cells (hematocrit), urine contains abnormal amount of protein (proteinuria), edema (a type of swelling), hypertensive disorder of pregnancy, bleeding, and spotting. At the first and last visits blood pressure was taken, and at some time prepregnancy and at the last visit, weight was assessed. The mother reported the number of alcoholic drinks she has a week at baseline and at the 32^nd week of gestation.

Finally, birth outcomes included the baby’s weight in grams, whether or not the birth was preterm (less than 37 weeks gestation), and whether or not the baby’s birthweight was low (less than 2500 grams).

Results: The nurse-visited condition positively impacted the mothers, compared with the control group: awareness of community services (mean of 5.5 known vs 4.9 known), childbirth class attendance (70 percent versus 54 percent), use of WIC for nutritional supplementation (mean of 2.2 vouchers vs 1.6 vouchers), diet (73.9 out of 100 on a scale measuring nutritional adequacy of diet vs 71.8 percent), father’s interest in the pregnancy (mean of 4.1 vs 3.7), expectation of a support person being present at labor (95 percent vs 87 percent), talking about pregnancy and personal problems to family and friends (mean of 38.4 vs 36.2), kidney infections (0 percent had one vs three percent had one), and number of cigarettes smoked per day (13.3 vs 16).

There were mixed impacts on birth weight and preterm births. The nurse-visited group had positive impacts only for two subgroups: Home visited mothers under 17 had higher average birth weights and fewer preterm births than their control group counterparts (3,335 grams vs 3,011 grams; 0 percent preterm vs 11.8 percent). Among those who reported smoking five or more cigarettes a day during pregnancy nurse-visited mothers had fewer preterm births (2.1 percent vs 9.8 percent).  The researchers reported negative findings for one subgroup: older non-smokers in the treatment group were more likely to have low birthweight babies, lower gestational lengths, and more preterm deliveries than older non-smokers in the comparison group (10.6% vs. 0% low birth weight; 38.9 vs 40 weeks gestation; and 11.8% vs. 3.1% preterm).

No significant impacts were found for the number of visits to service providers during pregnancy, number of calls to a physician or clinic, support person helping with the household, bladder infections, hematocrit, proteinuria, edema, hypertensive disorder of pregnancy, bleeding, spotting, blood pressure, number of alcoholic drinks a week, and weight gain during pregnancy.

Olds, D. L., Henderson, C. R., & Kitzman, H. (1993). Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life? Pediatrics, 94(1), 89-98.

Evaluated Population: See above.

Approach: See above for random assignment and exclusion of nonwhites. The researchers combined Treatment Groups 1 & 2 because there were no statistically significant differences in outcomes between them. They analyzed Groups 3 and 4 separately because group 3 mothers received home visits through their pregnancy, while group 4 mothers received home visits until their children were 24 months.

This study measured IQ, new cases of child abuse and neglect, hazards in the home, poisonous substances in reach of children, injuries and ingestions, child behavioral/parental coping problems in physician’s record, visits to the emergency room, days spent in the hospital, interviewer’s rating of mother’s warmth, interviewer’s rating of mother’s control, inventory of stimulation available to the child at home, stimulation of child’s language skills, provision of toys, games, and reading materials, and frequency of punishment. IQ was measured at 12, 24, 36, and 48 months. The rest of the measures were at 34 and 46 months. All means reported took into account covariates, and that is the reason some of the findings differ from other reports, for example, the program had no impact on IQ at 34 or 46 months in this study, but Olds et al did find an impact in their 1994 article at 46?? months.

Results: Positive program impacts were found for nurse visited individuals in the pregnancy/infancy group, compared with the control-group mothers: hazards in the home at 34 (.22 vs. .38 hazards) and 46 months (.21 vs. .46); child injuries and ingestions (0.3 of them vs 0.6), child behavioral/coping problems in physicians’ records (0.4 problems vs 0.7 problems), visits to the emergency room (1 time vs 1.5 times), and

at the 46^th month the mothers avoided punishing their children fewer times (2.8 vs 3.2).

For low-income, unmarried women, the nurse-visiting program had impacts for the pregnancy/infancy group mothers compared with the control mothers: the parent’s stimulation of the child’s language skills at the 34^th month (mean of 6.1 vs 5.1) and the provision of toys, games, and reading materials at the 34^th month (mean of 8.5 vs 7.3).

Nurse-visited children in the pregnancy/infancy group spent more days on average in the hospital than the comparison group (0.5 vs 0.3). One nurse-visited outlier who spent 23 days in the hospital is mostly responsible for the higher mean number of days in the hospital. The program had a significant impact on the low-income, unmarried women subgroup as well (0.65 vs 0.13 days).

The research showed no differences in IQ at 34 or 46 months or new cases of abuse and neglect between 25 and 49 months between the treatment and control groups. There were also no differences in hospital admissions.

Olds, D. L., Henderson, C. R., & Tatelbaum, R. (1994). Prevention of intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics, 93(2), 228-233.

Evaluated Population: See above. This particular study looks at a subset, however: women who smoked ten or more cigarettes a day at baseline.

Approach: See above for random assignment, exclusion of nonwhites, and combining treatment groups 1 and 2. Measures were cigarettes per day at the 34^th week of pregnancy, no alcoholic drinks in the last week of pregnancy (34^th week), illegal drug use (3^rd trimester), quality of diet (34^th week), maternal weight at end of gestation, birth weight, head circumference, length of gestation, five min Apgar score, days in the neonatal intensive care unit, illegal drug use, inventory of stimulation available to the child at home (assessed at 10 months, 22 months, 34 months, and 46 months), maternal depression at 46 months, and IQ at 12 months, 24 months, 36 and 48 months.

The primary analyses compared control group women who smoked 10+ cigarettes a day with women who had received home visiting either during pregnancy only or during pregnancy and up to 24 months of the child’s life.  

Results: Nurse-visited children had a higher IQ on average at 48 months, compared with the control group (mean IQ of 112.20 vs. 107.6). The program had a positive impact on the number of cigarettes smoked and the mothers’ quality of diet at the end of the pregnancy. The researchers concluded that the changes in the mothers’ diet and smoking during pregnancy (both shown to be program impacts in previous articles of this evaluation) were primarily responsible for higher IQ scores among the nurse-visited children.

Olds, D. L., Henderson, C. R., Kitzman, H., & Cole, R. (1995). Effects of prenatal and infancy nurse home visitation on surveillance of child maltreatment. Pediatrics, 95(3), 365-372.

Evaluated Population: See above. This particular study looks at a subset of 56 white families in the sample who had a state-verified report of child abuse or neglect in the first four years of the child’s life.

Approach: See Olds et al. 1988 above for random assignment. See Olds et al. 1993 above for discussion of the separation of treatment groups 3 and 4 in the analysis. This article analyzed measures of intellectual functioning, use of car seats or safety belts in the car, visits to physicians for injuries or ingestion, emergency department visits, and hazardous exposures observed in the home.

The following were measured at 25 months and 50 months: scheduled health supervision visits, scheduled health supervision visits with a problem or initial sick visit, behavioral/coping problems in physician record, number of emergency department visits, emergency department visits for injuries/ingestion, hospital admissions, number of days hospitalized, and number of injuries/ingestions in the physicians’ records. Hazardous exposures observed in the home, intellectual functioning, and use of car seats or safety belts in the car were measured at 34 months and 46 months.

Results: Positive impacts were found for hazardous exposures observed in the home at 46 months, number of injuries/ingestions in the physician record, number of emergency department visits, interviewer’s rating of how controlling the mother is of the child, and provision of toys, games, and reading materials at 46 months.

No significant impacts were found for IQ, use of car seats or safety belts in the car, scheduled health supervision visits, scheduled health supervision visits with a problem or initial sick visit, behavioral/coping problems in physician record, emergency department visits for injuries/ingestion, hospital admissions, and number of days hospitalized. In addition, the program did not have a significant impact on hazardous exposures observed in the home at 36 months or provision of toys, games, and reading materials at 36 months.

No significant impacts were found for a range of maltreatment measures collected from Child Protective Service Records. The authors speculate that the lack of differences between the treatment and control groups was due in part because the treatment group was probably subject to earlier and more reports to Child Protective Services.

Study Limitations: The sample size was small, and when the researchers examined the differences between the control and treatment groups they were using approximately 41 cases (about 28 cases in the control group and 13 cases in the Treatment 4 group). Thus, the statistical power of the analyses were limited. For many outcomes, such as IQ, number of scheduled health supervision visits, the number of scheduled health supervision visits problems or initial sick visits, the number of behavioral/coping problems among children in the physician records, the number of emergency department visits for injuries/ingestion and the number of hospital admissions there was a consistent pattern showing that the outcomes were most negative among the control group, more positive for the Treatment 3 group (home visiting through pregnancy), and most positive for the Treatment 4 group (home visiting through 24 months), which suggests that a larger sample size may have resulted in more statistically significant impacts.

Olds, D., Henderson Jr., 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 controlled trial. Journal of the American Medical Association, 280(14), 1238-1244.

Evaluated population: Children of mothers in the Nurse Home Visitation program (now called the Nurse-Family Partnership) from April 1978 through September 1980 in Elmira, N.Y. (see above studies).

Approach: The objective of the study was to examine the long-term impacts of the Nurse Home Visitation Program on children 15 years after the program—specifically, the impacts on children’s antisocial behavior.  Data were gathered from 148 of the control group’s children and 176 of the experimental group’s children.  The mothers of 79 of the children in the experimental group had received nurse visits from pregnancy through the child’s birth (the “pregnancy group”) and the mothers of 97 had received nurse visits from pregnancy until the child’s second birthday (the “pregnancy/infancy group”). Measurement instruments used were children’s self-reported delinquency, school records of suspension, teachers’ reports of behavior in school, parent’s report, Achenbach Youth Self-Report of Problem Behaviors, and county records.

Results: This study showed few statistically significant findings, but the program seems to be effective for those in the low-income, unmarried subgroup.

Children in the pregnancy/infancy group reported significantly fewer arrests (0.16-0.17 arrests for the intervention groups and 0.36 arrests for the control group).  However, children in this group also reported significantly more police stops from birth to age 15 than children in the other groups (an average of 2.25 stops vs. 0.53 stops for the pregnancy group and 0.80 stops for the control group).  The researchers attribute this higher number of police stops to sampling or reporting bias.  Children in the pregnancy/infancy group also reported significantly fewer convictions and violations of probation (0.10 convictions/probation violations vs. 0.06 for the pregnancy group and 0.27 for the control group).  These impacts were strongest for children of poor, unmarried mothers from low SES families.  Among children in this subgroup, those in the pregnancy/infancy group experienced an average of 1.46 stops by police, 0.20 arrests, and 0.09 convictions or violations of probation.  For children in the pregnancy group, these numbers were 0.78, 0.15, and 0.07, respectively; for children in the control group, they were 1.16, 0.45, and 0.47, respectively.

Children in both experimental groups who were born to poor, unmarried mothers from low SES backgrounds reported smoking significantly fewer cigarettes per day than their counterparts in the control group. Children in the pregnancy/infancy group reported smoking 1.5 cigarettes, children in the pregnancy group 1.32 cigarettes, and children in the control group 2.5 cigarettes.  Children in the pregnancy/infancy group born to poor, unmarried mothers from low SES backgrounds reported consuming alcohol on significantly fewer days in the last 6 months than the control group.  Children in the pregnancy/infancy group reported drinking alcohol an average of 1.09 days and children in the control group reported an average of 2.49 days.  Children in the pregnancy subgroup reported drinking alcohol an average of 1.84 days, a difference that is not statistically significant.

Low SES, unmarried mothers in the pregnancy group reported significantly fewer behavioral problems for their children due to alcohol and drug use (0.15 problems) than their counterparts in either the pregnancy/infancy group (0.62 problems) or the control group (0.34 problems).  Teacher reports did not indicate differences among the three groups in school behavior.

Olds, D. L., Robinson, J., O’Brien, R., Luckey, D. W., Pettitt, L. M., Henderson Jr., C. R., Ng, R. K., Sheff, K. L., Korfmacher, J., Hiatt, S., & Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110(3), 486-496.

Evaluated population: Low-income women (N=735) from 21 clinics in the Denver, CO, area.  Women in the study had no previous live births and either qualified for Medicaid or had no private health insurance.  Women were randomly assigned to one of two experimental groups or a control group: 245 women received home visits from a paraprofessional, 235 received home visits from a nurse, and 255 women were assigned to the control group.

Approach: The objective of the study was to determine the effectiveness of the Olds model of home visiting by paraprofessionals and by nurses.  Measurement instruments used were interviews with the mothers, analysis of videotapes of mother-infant interactions at all lab and home postpartum assessments, analysis of videotapes of infants’ emotional reactivity, and the Mental Development Index was used to assess the child’s functioning at the 24 month follow-up. It should be noted that women in the nurse group received significantly more home visits than women in the paraprofessional group: an average of 6.5 visits during pregnancy and 21 home visits during infancy vs. an average of 6.3 home visits during pregnancy and 16 home visits during infancy for the paraprofessional group.

Results: Women in the group seen by paraprofessionals showed a slight trend toward fewer subsequent pregnancies or births in the 24 months following delivery, compared with the control group.  Thirty three percent of women in the paraprofessional group had a subsequent pregnancy at 24 months compared with 41 percent in the control group and 13 percent of women in the paraprofessional group had a subsequent birth compared with 19% in the control group.  Women classified as having low resources in the paraprofessional group had significantly higher scores on measures of mother-infant responsive interaction (99. 5) than their counterparts in the control group (97.5).

In the group seen by nurses, women who smoked at the start of the intervention had significantly greater reductions (259.00 ng/mL) in nicotine levels than smokers in the control group (12.32 ng/mL).  Women in the nurse-visited group were significantly less likely to have a subsequent birth or pregnancy in the 24 months following delivery than women in the control group.  Twenty nine percent of women in the nurse-visited group had a subsequent pregnancy at 24 months compared with 41 percent in the control group and 12% of women in the nurse-visited group had a subsequent birth compared with 19 percent in the control group.  Women in the nurse group were employed for longer periods on average (6.8 months) in the second year following delivery than women in the control group (5.7 months).  Women in the nurse group showed significantly higher levels of mother-infant responsive interaction (mean score=100.3) than women in the control group (mean score=99).  Furthermore, children of women in the nurse-visited group were less likely to exhibit emotional vulnerability to fear stimuli (16 percent) than children of women in the control group (25 percent).  Children in the nurse group were also less likely to exhibit low emotional vitality to anger stimuli (13 percent) than children in the control group (32 percent).  Children in the nurse-visited condition were also significantly less likely to have language delays (six percent) at 21 months compared with the control group (12 percent).  Children who were born to mothers with low psychological resources in the nurse-visited group had higher levels of language development (101.5) at age 21 months than children in the control group (96.85) and higher mental development at 24 months (90.2 for nurse-visited, 86.2 for control).

Children in paraprofessional-visited conditions had lower language development compared with children who were visited by nurses.  Other than this difference, there were no significant impacts observed between the two interventions.

Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., Isacks, K., Sheff, K., & Henderson Jr., C. R. (2004).  Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial.  Pediatrics, 114(6), 1560-1568.

Evaluated Population: See above on 21 clinics in Denver.  Across the three conditions, 14-16 percent of women were African-American, 44-47 percent were Mexican-American, and 33-37 percent were Caucasian.  The average age of the women ranged from 19.46-20.14 years.  10.97-20.75 percent of participants were below the poverty line and the average annual income of participants was between $12,792-13,566.

Approach: Participants were randomly assigned to conditions in a three-strata randomization process based on race, gestational age at enrollment, and region.  Women in the control condition received free developmental screenings and referrals for their children at six, 12, 15, 21, and 24 months (N=255).  Women in the paraprofessional-visitation treatment condition received free screenings and the same referrals for their children along with paraprofessional home visits during the pregnancy up until the child was two years old (N=245).  Women in the nurse-visitation treatment condition received the same intervention as the paraprofessional condition except that home visitation was done by a registered nurse (N=235).

Mothers were assessed on self-report measures of general intelligence, mental health, sense of mastery, subsequent pregnancy outcomes, educational achievement, number of months working, use of welfare, marriage and cohabitation status, alcohol and marijuana use, and experiences of physical violence.  Children were assessed using mother-reported measures of externalizing behavior, rule-breaking, aggressive behavior, and whether they were in some form of care (school or day care).  Children’s home environment, language use, motor control, and behavior/emotion regulation were additional measures assessed by researchers.

Results: At the two year follow-up data collection women in the paraprofessional- condition were less likely to be married (32.2 percent) or live with the child’s biological father (32.7 percent) compared with women in the control condition (44.0 percent married and 43.1 percent living with child’s biological father).  Women in the paraprofessional-visited condition (15.13 months) worked more than those in the control condition (13.4 months) at the 2-year follow-up.  Women in the paraprofessional-visited condition also had a higher sense of mastery (101.3) and overall level of mental health (101.2) compared with the control condition (99.3, 99.2).  No significant impacts were found for the paraprofessional-visited condition on educational achievement, welfare use, marijuana and alcohol use, or domestic violence.  Women in the nurse-visited condition had longer intervals between their pregnancy at the start of the study and subsequent births (24.5 months) compared with the control condition (20.4 months).  At the four year follow-up interval, women in the nurse-visited condition were less likely to experience domestic violence (6.9 percent) and were also less likely to enroll their children in preschool or day care programs (59.4 percent) compared with the control condition (13.6 percent experienced domestic violence, 65.9 percent enrolled children in preschool or day care). The nurse-visited conditions did not have any effect on educational achievement, employment, welfare use, mental health, sense of mastery, use of alcohol or marijuana, and marriage or cohabitation status.

Children in the paraprofessional-visited condition had more responsive mothers (100.9) and more supportive home environments (24.6) compared to children in the control condition (98.7 responsiveness score and 23.35 home environment score).  The paraprofessional-visited condition did not have any impact on language development, executive functioning, emotional regulation, behavior, or mother-reported externalizing behavior.  When mothers’ had low psychological resources, children in the nurse-visited condition had more supportive home environments (24.6), better language development (91.39), superior executive functioning (100.2), and better researcher-rated behavior (100.41) compared with children in the control condition (respective scores of 23.4, 86.7, 95.5, 96.7).  Nurse-visitation did not have any impacts on mother-child interaction, emotional regulation, or externalizing behavior.

Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D. W., Henderson Jr., C. R., Hanks, C., Bondy, J., & Holmberg, J. (2004).  Effects of nurse home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial.  Pediatrics, 114(6), 1550-1559.

Evaluated Population: Women (N=1139) from the Memphis area who were pregnant and less than 29 weeks into the gestation period.  Women had to have at least two of the following risk factors to be included in the study: unmarried, less than 12 years of education, or unemployed.  Participants also had to have no previous live births and no known conditions which would contribute to fetal growth retardation or preterm delivery.  92 percent of participants were African-American, 98 percent were unmarried, 64 percent were under the age of 18, and 85 percent were from federally defined poverty-level households.

Approach: Participants were randomly assigned to one of four treatment conditions.  The first treatment consisted of free taxicabs to scheduled prenatal care appointments (N=166).  Treatment 2 received free cab fares and received developmental screening and referrals for the child at six, 12, & 24 months (N=515).  Treatment 3 (pregnancy group) received free cab fares and nurse home-visiting services (NFP) during the pregnancy, 1 postpartum visit before discharge, and 1 visit at home post-birth (N=230).  Treatment 4 (pregnancy/infancy group) received the same services as treatment 3 but children were visited by nurses until the age of 2 (N=228).  Data from treatments 2 and 4 were analyzed in this study.  The researchers collected data on children when they had completed at least 7 months of kindergarten at follow-up intervals of 4.5 and six years after mothers’ initial intake into the study. 

Mothers were assessed on self-report measures of number and timing of subsequent pregnancies and births, substance use, behavioral problems, educational achievement, employment status, occupational type, welfare/food stamp/Medicaid receipt, marriage and cohabitation, duration of relationships, current partner’s education, partner’s employment, partner’s social class, domestic violence since the birth of the first child, and current partner’s relation to the child.  Children were assessed using mother-reported measures of internalizing and externalizing behavior problems.  Classroom behavior of students and school engagement were measured through teacher reports.  Children also responded to eight open ended stories and the content of their responses were analyzed to determine the presence of aggressive content/behavior, coherency and consistency, and parental warmth and empathy.

Results: Mothers in the nurse-visited condition had fewer pregnancies and longer intervals between first and second births (1.16 pregnancies and 34.28 month interval) than mothers in the control condition (1.38 pregnancies and 30.23 month interval).  Participants in the nurse-visited condition received welfare and food stamps for fewer months (7.21 months on welfare, and 9.67 months on food stamps) compared with participants in the control condition (8.96 months on welfare, and 11.50 months on food stamps).  Participants in the nurse-visited condition also had longer relationships with their current partners (54.36 months) compared with the control group (45.00 months).  No impacts of treatment were found on measures of mother’s sense of mastery, mental health, education, employment, whether married or in an other partnered relationship, living with father of the child, outcomes of subsequent pregnancies, current partner’s education or socioeconomic status, drug use, or domestic violence experience since first birth.

Children in the nurse-visited condition had higher scores of intellectual functioning (92.34) and receptive language (84.32) compared with the control group (90.24, 82.13).  Mothers reported fewer children with problems (1.8%) in borderline or clinical range on the Child Behavior Checklist compared with children in the control group (5.4%).  Children of mothers with low psychological resources benefited in other ways from the intervention.  Children in the nurse-visited condition had higher arithmetic scores (88.61) compared with children in the control condition (85.42).  Children in the intervention condition also had less dysregulated aggression evident in their open-ended story (98.58) and these stories were more often coherent (20.90) when compared with the stories told by children in the control group (101.10 for mean aggression and 29.84 mean incoherency score).  No impacts of treatment were found on measures of child internalizing or externalizing behaviors, evidence of empathy in stories, reading achievement, or on teacher-reported behavior.

SOURCES FOR MORE INFORMATION

References

Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., et al. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. Journal of the American Medical Association, 278(8), 644-652.

Marcenko, M. O., & Spence, M. (1994). Home visitation services for at-risk pregnant and postpartum women: A randomized trial. American Journal of Orthopsychiatry, 64(3), 468-478.

Olds, D. (1999).  The Nurse Home Visitation Program.  The Future of Children, 9(1), 190-191.

Olds, D.L., Henderson, C.R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78(1), 65-78.

Olds, D., Henderson Jr., 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 controlled trial. Journal of the American Medical Association, 280(14), 1238-1244.

Olds, D. L., Henderson, C. R., & Kitzman, H. (1993). Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life? Pediatrics, 94(1), 89-98.

Olds, D. L., Henderson, C. R., Kitzman, H., & Cole, R. (1995). Effects of prenatal and infancy nurse home visitation on surveillance of child maltreatment. Pediatrics, 95(3), 365-372.

Olds, D. L., Henderson, C. R., & Tatelbaum, R. (1994). Prevention of intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics, 93(2), 228-233.

Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77(1), 16-28.

Olds, D. L., Henderson Jr., 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., Hill, P., & Rumsey, E. (1997).  Prenatal and early childhood nurse home visitation.  Office of Juvenille Justice and Delinquency Prevention: Issue No. NCJ172875.

Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D. W., Henderson Jr., C. R., Hanks, C., Bondy, J., & Holmberg, J. (2004).  Effects of nurse home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial.  Pediatrics, 114, 1550-1559.

Olds, D. L., Robinson, J., O’Brien, R., Luckey, D. W., Pettitt, L. M., Henderson Jr., C. R., Ng, R. K., Sheff, K. L., Korfmacher, J., Hiatt, S., & Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110(3), 486-496.

Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., Isacks, K., Sheff, K., & Henderson Jr., C. R. (2004).  Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial.  Pediatrics, 114, 1560-1568.

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

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

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.

Program categorized in this guide according to the following:

Evaluated participant ages: birth to age 15 for children and 15-24 years for mothers / Program age ranges in the guide: early childhood, mid-childhood, adolescence, youth, young adults

Program components: child care/early childhood education, clinic/provider based, home visiting, parent or family component

Measured outcomes: educational and cognitive development, social and emotional health, life skills, physical health, behavioral problems, teen pregnancy and reproductive health, mental health

KEYWORDS: Home Visitation, Employment, Reproductive Health, Adolescent Mothers, Skills Training, Child Care, Rural and/or Small Towns, Urban, Youth (16+), Young Adults (18-24), Academic Motivation/Self-Concept/Expectations/Engagement, Academic Achievement/Grades, Infants (0-12 months), Toddlers (12-36 months), Children (3-11), Early Childhood Education, Clinic/Provider-Based, Delinquency (e.g., truancy, vandalism, theft, assault, running away), White/Caucasian, Adolescents (12-17), Self-Esteem/Self Concept, Aggression/Violence/Bullying, Health Status/Conditions, Tobacco Use, Alcohol Use, Marijuana/Illicit/Prescription Drugs, Births, Public Assistance, Reading/Literacy, Other Social/Emotional Health, Other Relationships, Cost Information is Available.

Program information last updated 9/24/10