Program

Sep 24, 2010

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.

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 each.
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: 1) birth
outcomes; 2) the mother’s lifecourse development, such as educational
achievement 3) and workforce participation; and the quality of care the
parents provide their child.. 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 also organizes individual supervisory conferences
and weekly group conferences.
Costs:Average annual cost to
implement NFP is roughly $3,200 per family during the startup phase of the
program (first 3 years) and drops off to $2,800 per family after the program
has established itself. The extra cost associated with the startup phase is
due employee training and decreased efficiency.

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 32nd 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 32nd 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 32nd 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 46th 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 34th month (mean of
6.1 vs 5.1) and the provision of toys, games, and reading materials at the 34th
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 34th
week of pregnancy, no alcoholic drinks in the last week of pregnancy (34th
week), illegal drug use (3rd trimester), quality of diet (34th
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/

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.

 

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

 

©
Child Trends 2004

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