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