Date post: | 20-Jan-2016 |
Category: |
Documents |
Upload: | derek-sharp |
View: | 217 times |
Download: | 0 times |
Professor of Pediatrics, Psychiatry, and Preventive
Medicine
University of ColoradoUniversity of ColoradoHealth Sciences CenterHealth Sciences Center
David Olds, PhDDavid Olds, PhD
March 18, 2004
Baltimore, 1970
NURSE FAMILY PARTNERSHIP
• Program with power
– Make sense to parents
– Solid clinical underpinnings
– Nurse home visits from pregnancy through child age two
• Rigorously tested
FAMILIES SERVEDFAMILIES SERVED
• Low income pregnant women
– Usually teens
– Usually unmarried
• First-time parents
THREE GOALSTHREE GOALS
1. Improve pregnancy outcomes
2. Improve child health and development
3. Improve parents’ economic self-sufficiency
Preterm Delivery and Low Birthweight Neurodevelopmental Impairment Child Abuse and Neglect Childhood Injuries Rapid Successive Unintended Pregnancies Reduced Participation in Work Force Conduct Disorder Crime and Delinquency
Problems TargetedProblems Targeted
Child Neurodevelopmental
Impairment
Emotional/BehaviorDysregulation
CognitiveImpairment
Program
PrenatalHealth-Related
Behaviors
DysfunctionalCaregiving
Maternal Life Course
Closely SpacedUnplanned Pregnancy
Welfare Dependence
Substance Abuse
Negative Peers
AntisocialBehavior
SubstanceAbuse
Child/AdolescentFunctioning
TRIALS OF PROGRAMTRIALS OF PROGRAM
• Low-income whites
• Semi-rural
• Low-income blacks
• Urban
• Large portion of Hispanics
• Nurse versus paraprofessional visitors
Elmira, NY
N = 400
Memphis, TN
N = 1,138
Denver, CO
N = 735
CONSISTENT RESULTS CONSISTENT RESULTS ACROSS TRIALSACROSS 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
Elmira Maltreatment & Injuries (0 - 2 Years)
80% Reduction in Child Maltreatment(Poor, Unmarried Teens)
56% Reduction in Emergency Room Visits (12-24 Months)
9 10 11 12 13 14
100
60
50
40
30
20
10
0
Simultaneous Region of TreatmentDifferences (p < .10)
% A
bu
se /
Neg
lect
Maternal Sense of Control
Comparison
Nurse
LOW-INCOME, UNMARRIED 15-YEAR FOLLOW-UP
ELMIRA SUSTAINABLE RESULTS: Mothers
Verified reports of child abuse and neglect 79%
Behavioral problems due to drug or alcohol use 44%
Arrests 69%
ELMIRA SUSTAINABLE RESULTS: Adolescents
Arrests54%
Convictions 69%
Sexual Partners 58%
Cigarettes Smoked28%
Number of days consuming alcohol 51%
15-YEAR OLDS BORN TO UNMARRIED, LOW-INCOME
MOTHERS
Cumulative Cost Savings: Elmira
High-Risk Families
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
0 2 5 10 15 20 25 30 35 40 45 50 55 60 65
Cumulative dollars
perchild
Age of child (years)
Cumulative Costs
Cumulative savings
Memphis DesignMemphis Design
Urban Setting Sample (N = 1139 for prenatal and N = 743 for
postnatal) 92% African American 98% Unmarried 85% < Federal Poverty Index 64% < 19 years at intake
Randomized Trial
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
Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected
Nurse-Visited (n=204)
Age Length(in months) of Stay
Burns (10 & 20 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 (10 to lips) 3.5 15 Bilateral Subdural Hemotoma 4.9 19 Fractured Skull 5.2 5 Bilateral Subdural Hemotoma (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 (20 face/neck) 15.1 5 Burns (20 & 30 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
1.5
1.0
0.5
0.0
Nurse
Comparison
Simultaneous Region of TreatmentDifferences (p < .05)
60 70 80 90 100 110 120 130
Mothers’ Psychological Resources
No
. Hea
lth
Car
e E
nco
un
ters
wit
h In
juri
es/In
ges
tio
ns
Nurse
Simultaneous Region of TreatmentDifferences (p < 0.05)
Comparison
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
60 110 120 13080 90 10070
Mothers’ Psychological Resources
No
. Day
s H
osp
ital
i ze d
wi t
h In
juri
e s/ In
ge s
tio
ns
31% Fewer Closely Spaced (<6 months) Subsequent Pregnancies
50% Fewer Subsequent Therapeutic Abortions
30% Fewer Subsequent Admissions to Neonatal Intensive Care
3.64 Fewer Months of Welfare Use
32% Increase in Father Presence in Household
50% Increase in Marriage
Enduring Effects on Maternal Life-Course in Memphis
Kitzman, Olds, Sidora, et al. Journal of the American Medical Association, April 19, 2000 1983-1989.
Higher IQ’s
Better language development
Fewer mental health problems
Growing Effects on Child Development
Memphis 6-Year
Denver DesignDenver Design
735 Families
NursesN=236
ControlsN=255
ParaprofessionalsN=244
Denver Maternal Characteristics
Married 13%
Mexican American 46%
African American 17%
European American(Non-Hispanic) 35%
Monolingual Spanish Speakers 4%
Cigarette Smokers 25%
Pattern of Denver Program Effects
Maternaland
ChildFunctioning
Comparison Para Nurse
100
0
-100
-200
-300
-400
Change in Cotinine FromIntake to End of Pregnancy
Control-36.6 Para
-73.8
Nurse -235.6*
*P < .05
ChangeIn
Cotinine
Preschool Language Scale 21 months(Born to Low-Resource Mothers)
95
96
97
98
99
100
101
102
Comparison Para Nurse
PC-N = .04
Child Executive Functioning Index 4-Years
(Born to Low-Resource Mothers)
92
93
94
95
96
97
98
99
100
101
Comparison Para Nurse
Pc-p = .06, ES = .29; Pc-n = .000, ES = .47
Child Activity Level - 4-Years(Born to Low-Resource Mothers)
2.15
2.2
2.25
2.3
2.35
2.4
2.45
2.5
2.55
2.6
Comparison Para Nurse
Pc-n = .02 ES = .39
Now operating in over 250 counties in 23 Now operating in over 250 counties in 23 states, serving over 12,000 families per year.states, serving over 12,000 families per year.
NATIONAL REPLICATION
• Nurturing Community, Organizational, and State Development
• Training and Technical Assistance
• Program Guidelines
• Clinical Information System
• Assessing Program Performance
• Continuous Improvement
FROM SCIENCE TO PRACTICE
Effective Replication of the NFPEffective Replication of the NFP
13
3
77
46
5
1
3
112
1
1
30
4
1
6
1
2
23
2
1
3
8
* Numbers indicate number of counties in which the program serves clients
Communities Served as of January 2004
1
Typical Sources of FundingTypical Sources of Funding
Medicaid TANF Child Welfare Maternal and Child Health Juvenile Justice