Professor of Pediatrics, Nursing, and Public Health University of Colorado Nurse Family Partnership David Olds, PhD November 13, 2014

Baltimore, 1970

NURSE FAMILY PARTNERSHIP Prenatal and infancy home visiting by nurses Focused on low-income mothers with no previous live births Clarity in goals, objectives, and methods Activates and supports parents’ instincts to protect their children Strengths-based

NURSE FAMILY PARTNERSHIP’S THREE GOALS 1.Improve pregnancy outcomes 2.Improve child health and development 3.Improve parents’ health and economic self- sufficiency

TRIALS OF PROGRAM Low-income whites Semi-rural Low-income blacks Urban Large portion of Latino families Nurse versus paraprofessional visitors Elmira, NY 1977 N = 400 Memphis, TN 1987 N = 1,138 and N=743 Denver, CO 1994 N = 735

CONSISTENT RESULTS ACROSS TRIALS  Prenatal health  Children’s injuries  Children’s language and school readiness (low resource mothers)  Children’s behavioral problems  Children’s depression/anxiety  Children’s substance use  Maternal Impairment due to substance use  Short inter-birth intervals  Maternal employment  Welfare & food stamp use

Indicated Cases of Child Abuse and Neglect 0 to 15 Years - Elmira *P=.03 JAMA, 1997;278:

Number of Life-Time Arrests Elmira Youth - Age 19 P=.02, IR = 0.49 Arch Pediatr Adolesc Med 164(1) 9-15

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  2.4 SD above mean neighborhood adversity

Services Treatment 1 N=166 Treatment 2 N=514 Treatment 3 N=230 Treatment 4 N=228 Transportation for prenatal care X X X X Screening and referral for children X X Prenatal/ neonatal home visiting X X Infant and toddler home visiting X Services Provided in Each Treatment Condition Memphis

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 JAMA 1997; 278:

Nurse Simultaneous Region of Treatment Differences (p < 0.05) Comparison Mothers’ Psychological Resources No. Days Hospitalized with Injuries/Ingestions

Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected Nurse-Visited (n=204) AgeLength (in months)of Stay  Burns (1 0 & 2 0 to face)  Coin Ingestion  Ingestion of Iron Medication JAMA 1997; 278:

Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected - Comparison (n=453) Age Length (in months) of Stay  Head Trauma  Fractured Fibula/Congenital Syphilis  Strangulated Hemia with Delay in Seeking  Care/ Burns (1 0 to lips)  Bilateral Subdural Hematoma  Fractured Skull  Bilateral Subdural Hematoma (Unresolved)/ Aseptic Meningitis - 2nd hospitalization  Fractured Skull  Coin Ingestion  Child Abuse Neglect Suspected  Fractured Tibia  Burns (2 0 face/neck)  Burns (2 0 & 3 0 bilateral leg)  Gastroenteritis/Head Trauma  Burns (splinting/grafting) - 2nd hospitalization  Finger Injury/Osteomyelitis23.0 6

Reading & Math Achievement – Age 12 (Born to Low-Resource Mothers) p=.009, Effect Size = 0.25 Arch Pediatr Adoles Med, 164(5)

Percent of Children Who Used Tobacco, Alcohol, or Marijuana (Last 30 Days) Memphis – Child Age 12 P =.04 OR = 0.31 Arch Pediatr Adoles Med, 164(5)

Percent of Children with Depression- Anxiety – Child Age 12 P =.04 OR = 0.63 Arch Pediatr Adoles Med, 164(5)

Copyright restrictions may apply. control groups over time Total Discounted Government Spending (2006 US dollars) after Birth of First Child for Food Stamps, Medicaid, & AFDC/TANF

 All mothers assigned to treatments 1- 4  All children assigned to treatments 2 & 4 National Death Index Review

Survival plots for intervention and control mothers – all causes of death (T1+T2 vs. T3 p=.007; T1+T2 vs. T4 p=.19; T1+T2 vs. T3+T4 p=.008) JAMAPEDIATRICS pages E1-E7.July 7, 2014

* Sudden Infant Death Syndrome, injury, homicide (T2 vs. T4 p=.02) JAMAPEDIATRICS pages E1-E7.July 7, 2014 Survival plots for intervention and control children - preventable causes of death*

Tip of the Iceberg Health Disparities Cardiovascular disease Type-2 Diabetes Depression Cognitive decline

Pattern of Denver Program Effects Maternal and Child Functioning ComparisonParaNurse

Washington State Institute for Public Policy Economic Analysis (2011) Nurse Family Partnership produced large return on investment: –Implementation costs $9,421 –Benefits $30,325 –Return on investment $20,904

Coalition for Evidence-Based Policy Committed to reducing waste by identifying interventions that meet high evidentiary standards “Top Tier” interventions –Well designed and conducted randomized controlled trials –Replicated findings –Community settings –Sizable and sustained effects –Outcomes of clear public health, educational or social significance

 Support Organizational and Community Capacity  Education and Consultation  Program Guidelines  Information System  Assessing Program Performance  Continuous Improvement FROM SCIENCE TO PRACTICE

27 Nurse-Family Partnership is a growing, national program 43 States that NFP serves Number of counties NFP is serving Where we work 551 Tribal agencies are denoted by Band Map does not include program in U.S. Virgin Islands © Copyright 2014 Nurse-Family Partnership. All rights reserved.

Research Focused on Improving Program Model and Implementation Participant retention and completed home visits Intimate partner violence New method to observe & promote caregiver-child interaction Maternal depression and anxiety Development of STAR (Strength and Risk) framework to guide program implementation Pediatrics 2013; 132; S110

International Replication No presumptions Adaptation Pre-test and small-scale trial Larger trial Faithful replication of adapted program International work: –UK – England, Scotland, Northern Ireland –Australia – aboriginal families –Netherlands –Canada – ON and BC –American Indians & Alaskan Natives

Model Development Original Trials Trial 1 Trial 2 Trial 3 Articulate Essential Model Elements Develop/Test Model Innovations Studies of Implementation Process International Replication Adapt and Test Original Model US Community Replication Community Preparation Ed/Coaching of Nurses Performance Monitoring Continuous Quality Improvement