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Programs that Work

Nurse Family Partnership


Program Info
Program Overview
Program Participants
Evaluation Methods
Key Evaluation Findings
Probable Implementers
Funding
Implementation Detail
Issues to Consider
Example Sites
Contact Information
Available Resources
Bibliography
Last Reviewed

 

Program Info

Outcome Areas
Healthy and Safe Children
Children Succeeding in School
Strong Families

Indicators
Youths not using alcohol, tobacco, or illegal drugs
Students performing at grade level or meeting state curriculum standards
Children not experiencing physical, psychological or emotional abuse
Families increasing economic self-sufficiency
Babies born weighing more than 5.5 pounds and improving outcomes for low birth weight babies
Children and youth not engaging in violent behavior or displaying serious conduct problems
Children experiencing good physical health

Topic Areas

     Age of Child
       Early Childhood (0-8)
     Type of Setting
       Health Care Provider
       Home Visiting
     Type of Service
       Family Support
       Health Care Services
       Health Education
       Parent Education
     Type of Outcome Addressed
       Behavior Problems
       Child Abuse and Neglect
       Cognitive Development / School Performance
       Juvenile Justice
       Physical Health
       Poverty / Welfare
       Substance Use and Dependence
       Teen Sex / Pregnancy
       Violent Behavior

Evidence Level  (What does this mean?)
Proven

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Program Overview

The Nurse Family Partnership program (previously named the Prenatal and Infancy Nurse Home Visitation Program) provides home visits by registered nurses to first-time mothers, beginning during pregnancy and continuing through the child's second birthday. The program has three primary goals: (1) to improve pregnancy outcomes by promoting health-related behaviors; (2) to improve child health, development, and safety by promoting competent caregiving; and (3) to enhance parent life-course development by promoting pregnancy planning, educational achievement, and employment. The program also has two secondary goals: to enhance families' material support by providing links with needed health and social services, and to promote supportive relationships among family and friends.

The program was originally developed to address the underlying causes of antisocial behavior. Antisocial behavior is defined as behavior that violates social rules or harms others. When this behavior begins at an early age, it is likely to be more severe and is more likely to persist than antisocial behavior that begins in adolescence. Three main factors have been found to be associated with early onset of antisocial behavior:

  • Neurodevelopmental impairment of the fetus. Children of women who engage in risky behaviors (cigarette, alcohol, or drug use) are more at risk for this kind of impairment.

  • Dysfunctional care giving, which generally refers to inadequate parental provision of material and emotional care.


  • Maternal life-course development. Children of women who are on welfare, are unmarried, are high school dropouts, or who have three or more children are more likely to have children with reported behavioral problems.

The three primary goals of the program directly address these three main risk areas.

The content of the program is grounded in three theories: human ecology, human attachment, and the theory of self-efficacy.
  • Human ecology theory emphasizes the importance of social context in human development. The program is introduced to first-time mothers because a first child represents a major change in the mother's life. The program continues into the early years of the child's life when the parent is still learning the parental role.

  • Attachment theory argues that a caregiver's level of responsiveness to her child can be traced to her own childrearing history and attachment experiences. By helping the parent to see herself as someone who deserves support and attention, she begins to see her child as deserving the same.

  • The theory of self-efficacy posits that differences in motivation and behavior are due to an individual's beliefs about how his or her efforts and the desired results are interconnected. Based on this theory, the program emphasizes helping mothers to set small achievable objectives that involve behavioral change and that will help them in dealing with similar problems in the future. Researchers conducting this intervention have observed that the women with the most success in the program originally felt they had very little control over their lives.
Since the first trial study in 1977, the program has evolved to put greater emphasis on the attachment and self-efficacy theories.

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Program Participants

The program is designed to serve first-time mothers. It is particularly aimed at new mothers who have additional risk factors, such as low socioeconomic status, being unmarried, or being young (under 19).

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Evaluation Methods

The program has undergone three randomized trials with different study populations. A study in Memphis, Tennessee, was mostly composed of African-American women; another in Elmira, New York, was primarily composed of white women. A third study in Denver, Colorado, involved women from a range of backgrounds, and this study was primarily focused on determining the program's effectiveness when delivered by paraprofessionals as compared with registered nurses.

In the Memphis study, the researchers actively recruited women from prenatal clinics who had no previous live births, were fewer than 25 weeks pregnant, and who had at least two of the following sociodemographic risk conditions: were unmarried, completed fewer than 12 years of education, and were unemployed. Of the 1,290 eligible women, 1,139 (88 percent) consented to participate and were randomly assigned to one of four treatment conditions. Randomization was stratified by the following characteristics in order to have roughly comparable groups: maternal race, maternal age, gestational age at enrollment, employment status of head of household, and geographic region of residence.

Group 1 (n = 166) received free prenatal care appointments and round-trip taxicab service, but they did not receive any postnatal treatment. Group 2 (n = 515) received the free screening plus transportation for prenatal and well-child care at 6, 12, and 24 months of age. These two groups were combined in all the evaluations to form the control group. Group 3 (n = 230) received the prenatal services offered to group 1, and nurse home visiting services during pregnancy. The women in group 4 (n = 228) received the pre- and post-natal services offered to women in group 2 plus the nurses continued the home visits through the child's second birthday.

Ninety-two percent of the women enrolled in the Memphis study were black, 98 percent were unmarried, and 85 percent had household incomes at or below the federal poverty level.

The Elmira, New York, study used the same methods, but it had a much smaller treatment group. This study identified 500 eligible women and enrolled 400 in the program study.

The Denver study was slightly different in its study design. Researchers recruited first-time mothers with no private insurance or who qualified for Medicaid. Of the 1,178 eligible women, 734 agreed to participate. These women were then assigned to one of three groups: a comparison group that received the usual screening (n = 255), a second group that received nurse visits through the child's second birthday (n = 235), and a third group that received visits from paraprofessionals through the child's second birthday (n = 244).

Dropout rates in the three evaluations ranged from 15 to 21 percent. The main reason for dropouts was passive refusal (the mother could not be located or would not respond). Other reasons included refusing services, moving out of the area, or the death of the child.

The trials looked at several indicators, including women's health-related behaviors during pregnancy, the quality of parental caregiving (including state-verified reports of child abuse and neglect), rates of subsequent pregnancy, educational achievement, participation in the workforce, and the use of welfare.

Interviews and assessments were carried out at several points during the program with all those initially randomized. At 34 and 46 months, the staff carried out interviews and assessments in the home. The Caldwell and Bradley Home Inventory scales were used to measure different aspects of parental caregiving. Observation checklists assessed the mother's warmth for, control over, and involvement with her child and the child's exposure to various hazards in the home. At 36 and 48 months, children went to the project offices for standardized testing, such as the Stanford-Binet test of intelligence. The evaluations included interviews with the mothers. The 15-year follow-up of the Elmira study also included interviews with the adolescents who had been in the study and recorded measures of truancy; running away from home; criminal activity; pregnancy; and drug, alcohol, or cigarette use. These measures were matched with school data and teacher reports.

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Key Evaluation Findings

Olds et al. (1986) found significant effects in the Elmira study:

  • women who were visited by registered nurses were more aware of the community services available to them, attended childbirth education classes more frequently, indicated that the fathers of their babies showed a greater interest in their pregnancies, and were more frequently accompanied by someone to the labor room

  • nurse-visited young adolescents (those 14 to 16 years old) had babies who were an average of 395 grams heavier than the babies of adolescents in the comparison group (3,423 grams compared with 3,028 grams)

  • nurse-visited smokers made greater reductions in the number of cigarettes smoked than did smokers assigned to the comparison group (a four cigarettes-per-day difference by the end of pregnancy).
Olds et al. (1994) found for the period during which the Elmira children were between 25 and 50 months of age
  • homes of nurse-visited families had significantly fewer hazards for children at the 34- and 46-month assessment

  • nurse-visited children had 40 percent fewer notations of injuries and accidental ingestions and 45 percent fewer notations of child behavioral and/or parental coping problems in physicians' records

  • during this period, nurse-visited children made 35 percent fewer visits to the emergency room.
Olds et al. (1997) found that compared with unmarried women of low socioeconomic status in the control group, nurse-visited women in Elmira of low socioeconomic status
  • received significantly fewer months of public assistance

    • 60.4 months of Aid to Families with Dependent Children versus 90.3 months among the control group

    • 46.7 months of food stamps versus 83.5 months among the control group.

  • had 43 percent fewer subsequent pregnancies

  • delayed the birth of their second child an average of 12 months longer.
The 15-year evaluation (Olds et al., 1998a) of the Elmira trial found that compared with the control group
  • children in group 4 had significantly fewer arrests, convictions, and violations of probation

  • among adolescents born to unmarried women with low socioeconomic status, those in group 4 reported

    • significantly fewer instances of running away

    • significantly fewer sexual partners

    • consuming alcohol on fewer days during the six months before the interview.

The evaluation of the Memphis trial (Kitzman et al., 1997), found

  • nurse-visited mothers reported attempted breast-feeding significantly more frequently than comparison women and were more likely to use other community services

  • by the 24th month of the child's life, nurse-visited women


    • had significantly fewer health care encounters in which injuries and accidental ingestions were detected, and their children were hospitalized for fewer days

    • had significantly fewer beliefs about childrearing that were associated with child abuse and neglect (such as lack of empathy, belief in physical punishment, unrealistic expectations for infants)

    • reported having significantly fewer subsequent live births than women in the comparison group (36 percent versus 47 percent).

Olds et al. (2004) completed a follow-up of the children and mothers involved in the Memphis program at six years. They found
  • nurse-visited women had

    • significantly fewer subsequent pregnancies (1.16 versus 1.38) and births (1.08 versus 1.28)

    • significantly longer relationships with their current partners (54 versus 45 months)

    • fewer months using welfare (7.2 versus 9.0) and food stamps (9.7 versus 11.5)

  • nurse-visited children had

    • higher intellectual functioning as measured by the Kaufman Assessment Battery for Children

    • higher vocabulary scores as measured by the Peabody Picture Vocabulary Test

    • fewer behavior problems as measured by the Achenbach Child Behavior Checklist

  • nurse-visited children born to women with low psychological resources (limited intellectual functioning, poor mental health, a low sense of control over their life circumstances) had

    • higher arithmetic achievement test scores

    • lower levels of aggression in their response to stories

    • told less incoherent stories.

Olds et al. (2007) completed a nine-year follow-up of the mothers and children involved in the Memphis study. They found that nurse visited women compared to the control group had
  • significantly fewer subsequent low birth weight infants (0.18 versus 0.27)

  • significantly fewer subsequent births (0.8 versus 0.9)

  • significantly longer relationships with their current partners (51 versus 44 months)

  • fewer months per year using welfare (5.2 versus 5.92) and food stamps (6.9 versus 7.8)

  • children that were less likely to die by preventable causes

  • children with higher grade-point averages (2.7 versus 2.4) and higher achievement test scores in math and reading in grades one to three.

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Probable Implementers

Nurses; public health, social welfare, and criminal justice officials; obstetricians; and pediatricians. Most typically, public health departments, visiting nurse associations, and hospitals will carry out the program.

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Funding

The Elmira trial was originally funded from the research division of the Maternal and Child Health Bureau, with later funding from a variety of public and private resources. The Memphis trial was supported in 1987 by the Maternal and Child Health Bureau, the National Institute for Nursing Research, the Robert Wood Johnson Foundation, the W. T. Grant Foundation, the Pew Charitable Trusts, and the Carnegie Corporation. The Colorado Trust was the primary funder of the Denver trial. Dissemination sites are self-funded, most often using Temporary Assistance for Needy Families, Medicaid, child abuse prevention, maternal and child health, substance abuse prevention, and county funds.

A RAND cost-benefit analysis (Karoly et al., 1998) evaluated the Elmira trial through the 15-year follow-up. The average cost of the program was $6,083. Savings accrued from four areas: increased tax revenues due to increased employment; decreased welfare outlays; reduced expenditures for education, health, and other services; and lower criminal justice system costs. Karoly et al. found that for high-risk families (unmarried mothers with low socioeconomic status), the overall savings is more than four times the cost of the program (average total savings of $24,694). They did not find a net savings for lower-risk families (average total savings of $3,775).

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Implementation Detail

Program Design

  • The home visitors focus on improving maternal health, promoting competent parenting, and enhancing parental life-course development.

  • The program serves first-time, low-income mothers and their families.

  • The home visits begin during pregnancy and continue through the second year of the child's life.

  • The home visitors are highly trained registered nurses who follow specific protocols during each visit and carry a maximum of 25 cases.

  • Home visitors involve family members and friends in the program and help families to use other community health and human services.
The nurse visits occur approximately every one to two weeks through most of the intervention, depending on the mother's delivery date or the age of the child. During the prenatal period, the nurses help women complete 24-hour diet histories and plot weight gains; try to facilitate a reduction in the use of cigarettes, alcohol, and drugs through behavioral analysis; and help women to identify the signs and symptoms of pregnancy complications and other health problems (urinary tract infections, sexually transmitted diseases, and hypertensive disorders).

After delivery, the nurses also educate women on how to recognize health problems with their child and whom to contact when their child becomes ill. They promote parent-child interactions by helping parents to understand a child's communicative signals, enhancing parents' interest in playing with their children, and creating safer households. Nurses also help women clarify their goals and solve problems that may have interfered with completing their education, finding work, or planning future pregnancies.

Curriculum

The nurses are trained to follow a very specific set of protocols and home visit guidelines, which they then adapt to each family's strengths and needs.

Staffing

Home-visiting registered nurses provide the core staff of the program. Program nurses typically are hired through local health departments, community health centers, or Visiting Nurses Associations of America. In some cases, the program has been administered through local hospitals or nonprofit, private organizations.

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Issues to Consider

This program received a "proven" rating. The program has undergone three randomized studies using large sample sizes (ranging from 400 to 1,189 women) and up to 15 years of longitudinal follow-up for the initial Elmira study. Comparisons between women who were visited by nurses and those who were not demonstrated significant effects from nurse visits on several measures of maternal health, maternal life-course development, child health and safety, and adolescent measures of delinquency.

In all the trials, the program was most effective for first-time mothers who exhibited multiple risk factors, most commonly being unmarried, young, and of low socioeconomic status. Compared with lower risk women in the program, they were more likely to show increased employment and fewer subsequent births. Their children also showed greater gains; the children were less likely to run away from home, they had fewer sexual partners, and they consumed less alcohol.

One implementation issue that remains unresolved is the comparison between nurses and paraprofessionals. The evaluation in Denver did show that there were some program differences between the two. Nurses concentrated on issues of personal health and parenting, whereas paraprofessionals emphasized environmental health and safety, social supports, and the mother's life-course development. Based on the goals of the program, the program developers suggest using nurses rather than paraprofessionals, but questions regarding cost-effectiveness and long-term effects still remain. In addition, nurses were more likely to retain contact with the mother and complete the program through the second year of the child's life than were paraprofessionals. The latter issue may be a factor in trying to keep the mothers in the program.

Note that all of the evaluations of this program have been conducted by the developers of the program, Dr. David Olds and his associates, and NFP has not been studied by an external evaluator.

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Example Sites

Original research sites: Elmira, New York; Memphis, Tennessee; and Denver, Colorado. The program also is being replicated in over 20 states in the United States.

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Contact Information

Nurse-Family Partnership
National Office
1900 Grant Street,
Suite 400
Denver, CO 80203-4307

866.864.5226 (toll free)
303.327.4240 (main)
303.327.4260 (fax)

info@nursefamilypartnership.org (email)

www.nursefamilypartnership.org (Web site)

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Available Resources

Detailed visit-by-visit protocols, training, and technical assistance are made available to organizations that commit to conduct the program in accordance with the program model and that have the financial resources and organizational capacity to do so. Specific training modules have been developed around issues of staff cultural competence. Further, program teaching materials have been translated into Spanish. An extensive list of publications is available on the research findings and the theoretical and clinical foundations of the program.

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Bibliography

Karoly, Lynn A., Peter W. Greenwood, Susan S. Everingham, Jill Hoube, M. Rebecca Kilburn, C. Peter Rydell, Matthew Sanders, James Chiesa,  Investing in Our Children: What We Know and Don't Know About the Costs and Benefits of Early Childhood Interventions,  Santa Monica, Calif.: RAND, MR-898-TCWF, 1998. As of May 26, 2009: http://www.rand.org/pubs/monograph_reports/MR898/ 

Kitzman, H., et al., "Effect of Prenatal and Infancy Home Visitation by Nurses on Pregnancy Outcomes, Childhood Injuries, and Repeated Childbearing: A Randomized Controlled Trial,"  Journal of the American Medical Association,  Vol. 278, No. 8, 1997, pp. 644-652. 

Olds, D., et al., "Does Prenatal and Infancy Nurse Home Visitation Have Enduring Effects on Qualities of Parental Caregiving and Child Health at 25-50 Months of Life?"  Pediatrics,  Vol. 93, 1994, pp. 89-98. 

Olds, D., et al., "Effects of Nurse Home Visiting on Maternal Life Course and Child Development: Age 6 Follow-up Results of a Randomized Trial,"  Pediatrics,  Vol. 114, 2004, pp. 1550-1559. 

Olds, D., et al., "Effects of Nurse Home Visiting on Maternal Life Course and Child Development: Age 9 Follow-up Results of a Randomized Trial,"  Pediatrics,  Vol. 120, 2007, pp. e832-e845. 

Olds, D., et al., "Effects of Prenatal and Infancy Nurse Home Visitation on Surveillance of Child Maltreatment,"  Pediatrics,  Vol. 95, 1995, pp. 365-372. 

Olds, D., et al., "Improving the Delivery of Prenatal Care and Outcomes of Pregnancy: A Randomized Trial of Nurse Home Visitation,"  Pediatrics,  Vol. 77, 1986, pp. 16-28. 

Olds, D., et al., "Improving the Life-Course Development of Socially Disadvantaged Parents: A Randomized Trial for Nurse Home Visitation,"  American Journal of Public Health,  Vol. 78, November 1988, pp. 1436-1445. 

Olds, D., et al., "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,  Vol. 280, No. 14, 1998a, pp. 1238-1244. 

Olds, D., et al., "Long-Term Effects of Nurse Home Visitation on Maternal Life Course and Child Abuse and Neglect: Fifteen-Year Follow-up of a Randomized Trial,"  Journal of the American Medical Association,  Vol. 278, No. 8, 1997, pp. 637-643. 

Olds, D., et al., "Reducing Risks for Antisocial Behavior with a Program of Prenatal and Early Childhood Home Visitation,"  Journal of Community Psychology,  Vol. 26, 1998b, pp. 65-83. 

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Last Reviewed

May 2009

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