# Presentation: 708949

## Professor of Pediatrics, Psychiatry, Nursing, and Preventive Medicine

University of Colorado
Health Sciences Center

National Institutes of Health

**University of Colorado**
**Health Sciences Center**
**National Institutes of Health**

**Using RCT’s to Test and Refine the Nurse-Family Partnership****David Olds, PhD**

- September 18, 2007

## Baltimore, 1970

**Baltimore, 1970**

## NURSE FAMILY PARTNERSHIP

**Program with power**
**Nurses visit families from pregnancy through child age two**
**Makes sense to parents**
**Solid empirical & theoretical  underpinnings**
**Focuses on parental behavior and context**
**Rigorously tested**

## FAMILIES SERVED

**Low income pregnant women**
**Usually teens**
**Usually unmarried**
**First-time parents**

## NURSE FAMILY PARTNERSHIP’STHREE GOALS

**Improve pregnancy outcomes**
**Improve child health and development**
**Improve parents’ economic self-sufficiency**

## Child Neurodevelopmental

**Child Neurodevelopmental**
**Impairment**

**Emotional/Behavior**
**Dysregulation**

**Cognitive**
**Impairment**

**Program**

**Prenatal**
**Health-Related**
**Behaviors**

**Dysfunctional**
**Caregiving**

**Maternal **
**Life Course**

**Closely Spaced**
**Unplanned Pregnancy**

**Welfare Dependence**

**Substance Abuse**

**Negative **
**Peers**

**Antisocial**
**Behavior**
**Substance**
**Abuse**

**Child/Adolescent**
**Functioning**

## TRIALS OF PROGRAM

**Low-income whites**
**Semi-rural**

**Low-income **
**	****blacks**
**Urban**

**Large portion of Hispanics**
**Nurse  versus paraprofessional visitors**

**Elmira, NY**
**1977**

**N = 400**

**Memphis, TN**
**1987**

**N = 1,138**

**Denver, CO**
**1994**

**N = 735**

## CONSISTENT RESULTS ACROSS TRIALS

**Improvements in women’s prenatal health **
**Reductions in children’s injuries**
**Fewer subsequent pregnancies**
**Greater intervals between births**
**Increases in fathers’ involvement**
**Increases in employment **
**Reductions in welfare and food stamps**
**Improvements in school readiness (low resource mothers)**
**Effects greatest for most susceptible**

## Elmira Maltreatment & Injuries (0 - 2 Years)

**80% Reduction in Child Maltreatment**
**	****(Poor, Unmarried Teens) – p=.07**
**56% Reduction in Emergency Room Visits (12-24 Months)**

## % Abuse / Neglect

- 9

- 10

- 11

- 12

- 13

- 14

- 100

-  60

- 50

- 40

- 30

- 20

- 10

- 0

**Simultaneous Region of Treatment**
**Differences (p < .10)**

**% Abuse / Neglect**

**Maternal Sense of Control**

**Comparison**

**Nurse**

## Slide 11

## ELMIRA SUSTAINABLE RESULTS: Benefits to Mothers

**ELMIRA SUSTAINABLE RESULTS: ****Benefits to Mothers**

**Days in Jail***

**98%**

- * Impact on days in jail is highly significant, but the number cases that involved jail-time is small, so the magnitude of program effect is difficult to estimate with precision

**15-YEAR FOLLOW-UP**

## ELMIRA SUSTAINABLE RESULTS: Benefits to Children

**ELMIRA SUSTAINABLE RESULTS: ****Benefits to Children**

**15-YEAR FOLLOW-UP**

- * Based upon family-court records of 116 children who remained in study-community for 13-year period following end of program.

## Maltreatment Reports Involving the Study Child by Treatment Status and Domestic Violence

- Simultaneous Region of Treatment Differences
- (_p_ < .05)

## Memphis Design

**Memphis Design**

**Urban Setting**
**Sample ****(N = 1138 for prenatal and N = 743  for postnatal)**
**  ****92****% African American**
**  ****98% Unmarried**
**  ****85% < Federal Poverty Index**
**  ****64% < 19 years at intake**
**   ****Neighborhood Disorganization 3.2 SD**
**     ****above national mean**

## Memphis Program Effects on Childhood Injuries (0 - 2 Years)

**23% Reduction in Health-Care Encounters for Injuries & Ingestions**
**80% Reduction in Days Hospitalized for Injuries & Ingestions**

## Mothers’ Psychological Resources

- 1.5

- 1.0

- 0.5

- 0.0

**Nurse**

**Comparison**

**Simultaneous Region of Treatment**
**Differences (p < .05)**

- 60

- 70

- 80

- 90

- 100

- 110

- 120

- 130

**Mothers’ Psychological Resources**

**No. Health Care Encounters**
**with Injuries/Ingestions**

## Mothers’ Psychological Resources

- Nurse

**Simultaneous Region of Treatment**
**Differences (p < 0.05)**

**Comparison**

- 3.5

- 3.0

- 2.5

- 2.0

- 1.5

- 1.0

- 0.5

- 0.0

- 60

- 110

- 120

- 130

- 80

- 90

- 100

- 70

**Mothers’ Psychological Resources**

**No. Days Hospitalized with Injuries/Ingestions**

## Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected

**Nurse-Visited (n=204)**

**	****	****	****	****	****	****Age****	****	****Length**
**	****	****	****	****	****(in months)****	****	****of Stay**
**   ****Burns (1****0 ****& 2****0 ****to face)****	****	****12.0****	****	****    2**
**   ****Coin Ingestion****	****	****	****12.1****	****	****    1**
**     ****Ingestion of Iron Medication****	****20.4****	****	****    4**
**	**
**	****	****	**

**Kitzman, H., Olds, D.L., Henderson, Jr., C.R., et al. *****JAMA *****1997; 278: 644-652.**

## Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected - Comparison (n=453)

**	****	****	****	****	****           ****Age                       Length**
**	****	****	****	****	****       ****(in months)                of Stay**
**   ****Head Trauma****	****	****	****	****	**** 2.4****	****	****     1**
**   ****Fractured Fibula/Congenital Syphilis****	****	**** 2.4****	****	****    12**
**    ****Strangulated Hemia with Delay in Seeking**
**     ****Care/ Burns (1****0**** to lips)****	****	****	**** 3.5****	****	****    15**
**   ****Bilateral Subdural Hematoma****	****	****	**** 4.9****	****	****    19**
**   ****Fractured Skull****	****	****	****	**** 5.2****	****	****     5**
**   **** ****Bilateral Subdural Hematoma (Unresolved)/**
**       ****Aseptic Meningitis - 2nd hospitalization****	**** 5.3****	****	****     4**
**   **** ****Fractured Skull****	****	****	****	**** 7.8****	****	****     3**
**   ****Coin Ingestion****	****	****	****	****10.9****	****	****     2**
**   **** ****Child Abuse Neglect Suspected****	****	****14.6****	****	****     2**
**   ****Fractured Tibia****	****	****	****	****14.8****	****	****     2**
**   ****Burns (2****0**** face/neck)****	****	****	****	****15.1****	****	****     5**
**   ****Burns (2****0**** & 3****0**** bilateral leg)****	****	****	****19.6****	****	****     4**
**   ****Gastroenteritis/Head Trauma****	****	****	****20.0****	****	****     3**
**   ****Burns (splinting/grafting) - 2nd hospitalization****	****20.1****	****	****     6**
**   ****Finger Injury/Osteomyelitis****	****	****	****23.0****	****	****     6**
**	****	**
**	****	****	**

## Childhood Mortality

**(per thousand live births) **
**Birth to Age Nine - Memphis**

** ****P = .08,   OR  = .21**

## Causes of Child Death 0-9 Years - Memphis

**Comparison (N=498)**
**Cause of Death          Age at Death-days**
**Extreme Prematurity                             3**
**Sudden Infant Death Syndrome         20**
**Sudden Infant Death Syndrome         35**
**Ill Defined Intestinal Infections           36**
**Sudden Infant Death Syndrome         49**
**Multiple Congenital Anomalies        152**
**Chronic Respiratory Disease **
**      ****Arising in Perinatal Period         549**
**Homicide Assault by Firearm          1569**
**Motor Vehicle Accident                    2100**
**Accident Caused by Firearm           2114**

**Nurse-Visited (N=222)**
**Cause of Death              Age at Death-days**
**   **
**   ****Chromosomal Abnormality                 24**

## Group Achievement Test Scores Reading & Math, Grade 1-3Born to Low-Resource Mothers

**p=.002, Effect Size = 0.33**

## PIAT Scores Reading & Math, Age 12Born to Low-Resource Mothers

**p=.009, Effect Size = 0.29**

## % Unsatisfactory Conduct Grades Memphis Grades 1- 6

**    ****OR females = 1.47, p=.399                            OR males = 0.55, p =.054**

## % Used Tobacco, Alcohol, or Marijuana Memphis – Child Age 12

** ****P = .024,   OR  = 0.29**

## Number of Days Used Tobacco, Alcohol, or Marijuana (Last 30 Days)

**Memphis – Child Age 12**

** ****P<.0001,   OR  = 0.17**

## Pattern of Denver Program Effects

**Maternal**
**and**
**Child**
**Functioning**

**Comparison**

**Para**

**Nurse**

## Change in Cotinine From

**100**

**0**

**-100**

**-200**

**-****300**

**-400**

**Change in Cotinine From**
**Intake to End of Pregnancy**

**Control**
**-36.6**

**Para**
**-73.8**

**Nurse**
**  ****-235.6***

***P****c-n**** < .05**

**Change**
**In**
**Cotinine**

## Slide 30

## Preschool Language Scale 21 months

**(Born to Low-Resource Mothers)**

**P****C-N**** = .04, ES = .40**

## Total Preschool Language Scale

**4 Years**
**(Born to Low-Resource Mothers)**

**P****C-P**** = .13, ES = .23; ****P****C-N**** = .04, ES = .31**

## Sensitive/Responsive Interaction

**4 Years**
**(Low-Resource Mothers)**

**P****C-P**** = .03, ES****C-P**** = .23;    P****C-N**** = .06, ES****C-N**** = .18**

## Executive Functioning Index - 4-Years

**(Born to Low-Resource Mothers)**

**P****c-p ****= .06, ES = .29; **** ****P****c-n**** = .000, ES = .47**

## % Domestic Violence – 4 Years

**P****C-P****=.88, OR****C-P**** = 1.05;    P****C-N**** = .05, OR****C-N**** = .47**

## Benefits Minus Costs of Child Welfare & Home Visiting Programs

**Nurse Family Partnership**
**Home Visiting for at-risk mothers/children**
**Parent-child interaction therapy**
**System of care/wrap around programs**
**Family Preservation Services Programs**
**Healthy Families America**
**Comprehensive Child Development Program**
**Infant Health and Development Program**
**Summary Report: **
- _[http://www.wsipp.wa.gov/rptfiles/04-07-3901.pdf](http://www.wsipp.wa.gov/rptfiles/04-07-3901.pdf)_

-  **$17,180**
**   ****$6,197**
**   ****$3,427**
**  ****-$1,914**
**  ****-$2,531**
**  ****-$4,569**
** ****-$37,397**
** ****-$49,021**

## Nurturing Community, Organizational, and State Development
Training and Technical Assistance
Program Guidelines
Clinical Information System
Assessing Program Performance
Continuous Improvement

**Training and Technical Assistance**
**Program Guidelines**
**Clinical Information System**
**Assessing Program Performance**
**Continuous Improvement**

**FROM SCIENCE TO PRACTICE**

## Slide 38