does prenatal and infancy nurse home visitation have ... · states during 2-year period after...

1994;93;89-98 PediatricsDavid L. Olds, Charles R. Henderson, Jr. and Harriet Kitzman

of Parental Caregiving and Child Health at 25 to 50 Months of Life?Does Prenatal and Infancy Nurse Home Visitation Have Enduring Effects on Qualities

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PEDIATRICS Vol. 93 No. I January 1994 89

Does Prenatal and Infancy Nurse Home Visitation Have Enduring Effects

on Qualities of Parental Caregiving and Child Health at 25 to 50 Months

of Life?

David L. Olds, PhD*; Charles R. Henderson, Jr4; and Harriet Kitzman, RN, PhD�

ABSTRACT. Objective. To examine, during the 3rd

and 4th years of life, the health, development, rates of

child maltreatment, and living conditions of children whohad been enrolled in a randomized trial of nurse homevisitation during pregnancy and first 2 years of their lives.

Design. Prospective follow-up of families who had

been randomly assigned to nurse-visited and comparison

conditions.

Setting. Study conducted in semirural community inupstate New York. Families dispersed among 14 other

states during 2-year period after children’s second birth-

days.Participants. Four hundred women were recruited

through a health department antepartum clinic and of-fices of private obstetricians and were registered before

30th week of pregnancy. All women had no previous livebirths and 85% were either teenaged (<18 years at regis-

tration), unmarried, or from Hollingshead social classesIV or V. Analysis focused on whites, who comprised 89%

of sample.Intervention. Nurse home visitation from pregnancy

through second year of the child’s life.Main Results. There were no treatment differences in

the rates of child abuse and neglect or children’s intel-lectual functioning from 25 to 48 months of age. Nurse-visited children, nevertheless, lived in homes with fewer

hazards for children; they had 40% fewer injuries and in-

gestions and 45% fewer behavioral and parental copingproblems noted in the physician record; and they made

35% fewer visits to the emergency department than didchildren in the comparison group. Nurse-visited motherswere observed to be more involved with and to punishtheir children to a greater extent than were mothers in thecomparison group. The functional meaning of punish-ment differed between the nurse-visited and comparison

families.Conclusions. The program does have enduring effects

on certain aspects of parental caregiving, safety of thehome, and children’s use of the health care system, but itmay be necessary to extend the length of the program for

families at highest risk to produce lasting reductions inchild abuse and neglect. Pediatrics 1994;93:89-98; childabuse, neglect, nurse home visitation, child, health, devel-opment.

From the *Depa�ent of Pediatrics, University of Rochester School of

Medicine and Dentistry, the �Department of Human Development andFamily Studies, Cornell University, and the §University of Rochester School

of Nursing.

Received for publication January 29, 1993; accepted June 10, 1993..

Reprint requests to (D.L.O.) Dept of Pediatrics, Box C 249-63, University of

Colorado Health Sciences Center, 4200 East 9th Avenue, Denver, CO 80262.

PEDIATRICS (ISSN 0031 4005). Copyright © 1994 by the American Acad-

emy of Pediatrics.

The US Advisory Board on Child Abuse and Ne-glect recently has concluded that child maltreatmentis a national emergency and has recommended that a

universal program of home visitation be developedfor all new parents to reduce this perniciousproblem.’2 Although the evidence to support this rec-

ommendation is increasing,�” it is still limited. Tworandomized trials support the efficacy of home visi-tation as a method of preventing maltreatment,� one

shows no effect,5 and two have produced equivocalresultsP7 Moreover, we know virtually nothing aboutthe extent to which home visitation services have any

lasting effect on the qualities of care that parents pro-vide to their children or on children’s health. In re-views of randomized trials of home visitation forpregnant women and parents of young children, we

concluded that the potential for the prevention of mal-treatment will be increased to the extent that it isplaced in the context of a comprehensive approach tothe promotion of maternal and child health and well-

being.6-9In earlier reports from the current trial, we showed

that a comprehensive program of prenatal and in-fancy nurse home visitation improved the outcomesof pregnancy,’#{176} reduced the rates of child abuse andneglect among high-risk families while the programwas in operation,4 improved the life course develop-ment of the children’s mothers,” reduced the risk ofintellectual delay associated with maternal smokingduring pregnancy,�2�l3 and reduced government ex-penditures for low-income families.’4 In the currentreport, we examine the extent to which the compre-hensively designed program of nurse home visitationstudied in earlier reports had enduring effects on

qualities of parental caregiving, child abuse and ne-glect, children’s intellectual functioning, and chil-dren’s use of health services during a 2-year period

after their second birthday (which marked the end of

the nurses’ visits with families).

RESEARCH DESIGN AND METHODS

The Setting

The study consisted of a randomized clinical trial conducted in

a small, semirural county of approximately 100 000 residents in

the Appalachian region of New York State. During the 2-year

follow-up period, the children and families were dispersed among

14 other states. At the time the study was initiated, the local

community was well served from the standpoint of both health

and human services. In spite of this abundance of services, the

community consistently exhibited the highest rates of reported

and confirmed cases of child abuse and neglect in the state be-

tween 1972 and 1982.’� Moreover, in 1981, the community was



90 HOME VISITATION AND CHILD HEALTH

rated the worst Standard Metropolitan Statistical Area in the

country in terms of its economic conditions.’6

The Sample

We actively recruited pregnant women if, at intake, they had no

previous live births, they were less than 26 weeks of gestation, and

they had any one of the following characteristics that predispose

to infant health and developmental problems: (1) young age (<19

years), (2) single-parent status, (3) low socioeconomic status. We

enrolled any woman who asked to participate, however, regard-

less of her age, marital status or income, if she had no previous live

births. This approach avoided creating a program that was stig-

matized as being exclusively for the poor, and by creating sample

heterogeneity, it enabled us to determine whether the effects of the

program were greater for families at higher risk. Women were

recruited through a free antepartum clinic sponsored by the health

department, the offices of private obstetricians, Planned Parent-

hood, the public schools, and a variety of other health and human

service agencies.

Approximately 10% of the target population was missed be-

cause of late registration for prenatal care. An additional 10% was

missed because some eligible women from the offices of private

obstetricians were not referred. Five hundred women were inter-

viewed between April 1978 and September 1980, and 400 were

enrolled. There were no differences in age, marital status, or edu-

cation between those women who participated and those who

declined. Ninety-eight of 452 whites (22%) declined to participate

compared with 2 (4%) of 48 others (46 blacks and 2 Asians). At

registration, 47% of the participating women were less than 19

years of age, 62% were unmarried, and 61 % came from families in

Hollingshead’s social classes IV and V (semiskilled and unskilled

laborers). Fifteen percent of the women were not at risk according

to the age, marital status, or socioeconomic status criteria, and 23%

possessed all three risk characteristics.

The 46 nonwhites were excluded from the analyses reported

here because this sample was too small to provide adequate sub-

class sizes when other factors of importance were included in the

statistical model. The analysis of the nonwhite sample is presented

elsewhere)7Participating families were assigned to one of the four treat-

ment groups outlined below. (Assignment procedures were

outlined in earlier reports.4”#{176})

Treatment Conditions

Treatment I . When the children were I and 2 years of age, an

infant specialist hired by the research project screened them for

sensory and developmental problems and referred those with sus-

pected problems to other specialists for further evaluation and

treatment.

Treatment 2. Families were provided free transportation for

regular prenatal and well-child care at local clinics and physicians’

offices through a contract with a local taxicab company, as well as

the sensory and developmental screening outlined in treatment I.

Treatment 3. Families were provided a nurse home visitor dur-

ing pregnancy, in addition to the screening and transportation

services. The nurses visited families approximately once every 2

weeks and made an average of nine visits during pregnancy. The

average visit lasted I hour and 15 minutes.

Treatment 4. Families received the same services as those in

treatment 3, but in addition the nurse continued to visit until the

children were 2 years of age. For 6 weeks after delivery the nurses

visited families every week; from 6 weeks to 4 months, they visited

every 2 weeks; from 4 to 14 months, every 3 weeks; from 14 to 20months, every 4 weeks; and from 20 to 24 months, every 6 weeks.

Under predetermined crisis conditions the nurses visited weekly.

As during pregnancy, the average visit lasted approximately I

hour and 15 minutes, but the mean number of visits completed

from birth through the end of the program was 23.

The Home Visitation Program

The nurse visitation program was designed to improve three

aspects of maternal and child functioning: (1) the outcomes of

pregnancy; (2) qualities of parental caregiving (including reducing

associated child health and developmental problems); and (3) ma-ternal life course development (helping women return to school,

find work, and practice family planning). Although the program

was designed explicitly to address risk factors for child maltreat-

ment, it intentionally was not identified as a child abuse preven-

tion program to reduce the potential for stigmatization of the

program and its participants.

In their work to improve these outcomes, the nurses helped

women improve their health-related behaviors, qualities of infant

caregiving, and personal development by encouraging them to set

small, achievable goals and to use problem-solving methods to

gain control over the difficulties they encountered. The women’s

accomplishments, in turn, enhanced their sense of competence in

managing future problems. In an effort to create a home environ-

ment that was more conducive to optimal health behavior, the

nurses involved other family members and friends in the preg-

nancy, birth, and early care of the child, and they linked families

with other needed health and human services. When the nurses

ended their work with families at the child’s second birthday, they

identified families with special needs and referred them to existing

community services so that families would be integrated into the

formal system of care. They performed this work in the context of

their establishing a long-lasting, therapeutic relationship with the

mother and family, and their emphasizing individual and family

strengths.

Five registered nurses were hired through a nonprofit private

agency expressly for this experimental program. Each nurse had a

caseload of 20 to 25 families from pregnancy through the child’s

second birthday. The nurses worked in two-person teams, with

each member serving as a backup for her partner. By visiting one

another’s families at least once during both pregnancy and in-

fancy, the members of the team were able to serve as ongoing

supports for one another on a day-to-day basis. Detailed descrip-

tions of the program are provided elsewhere.”�2’

Assessments and Definition of Variables

The interviews and assessments for this report were conducted

at registration (before the 30th week of pregnancy) and at the 34th,

36th, 46th, and 48th months of the children’s lives. At 34 and 46

months, staff members conducted interviews and observational

assessments in the families’ homes. At 36 and 48 months of life, the

children were brought to the project offices for standardized

testing. Except in a few cases in which women inadvertently dis-

closed their treatment assignments, all assessments were con-

ducted without awareness of the women’s and children’s treat-

ment assignment.

During the home visits, the interviewers completed the

Caldwell and Bradley Home Inventory.� The Home Inventoryincludes subscales that assess particular aspects of parental car-

egiving, such as the avoidance of punishment and the stimulation

of the child’s language skills, as well as characteristics of thephysical environment, such as the provision of toys, games, and

reading materials. Interobserver reliabilities for the Home Inven-

tory Total Scores were >95% at both the 34th and 46th months;

n = 28 and n = 24 paired observations, respectively.

At the 34th and 46th month in-home observations, the inter-

viewers also observed the mothers’ interactions with their chil-

dren and completed 7-point scales that rated the mothers’ warmth,

control, and involvement. Interobserver reliability estimates, ob-

tained for 30 pairs of observations at the 34th month observation

and 12 pairs at the 46th month, ranged from 70% to 83% for

identical responses, and from 92% to 100% when agreement was

indicated by scores within I point of one another.

The interviewers also completed an observation checklist mdi-

cating the degree of the child’s exposure to the following catego-

ries of hazards in the home: (1) chipped or flaking paint; (2) sharp

objects (broken glass, boards with protruding nails, knives, razor

blades, etc.); (3) danger of burns (pots or pans with handles turnedout, iron left out, exposed heaters and wood stoves, etc.); and (3)

dangerously placed objects that pose a risk for falls, such as those

on stairways. For each category of hazards, the interobserver re-

liability at 34 months exceeded 93% for identical responses (n = 30

pairs) and at 46 months exceeded 86% for identical responses

(n = 22 pairs).

At both 34 and 46 months, the interviewers asked questions

about the presence and accessibility of poisonous substances in the

home and the child’s use of car seats and safety belts when riding

in the car; responses were aggregated into scales that character-

ized the child’s exposure to poisonous substances in the home anduse of car seats and seat belts while riding in cars.



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1 1.5 2 2.5 3 3.5 4

RESULTS

Preintervention Treatment Conditions

As shown in our previous reports, before assign-

ment to treatment conditions, the women visited by

nurses and in the comparison group were equivalent

on all standard sociodemographic background char-

acteristics.4 Moreover, there were no treatment dif-

ferences in newborn complications, chronic diseases,or handicapping conditions. They differed, however,on some social support and psychological character-istics. In contrast to the women in the comparisongroup, there was a trend for the nurse-visited group

to expect less accompaniment to labor and delivery;the nurse-visited unmarried women had greater

senses of control; and the poor, unmarried teenagers

assigned a nurse reported receiving greater support

from their boyfriends. Because sense of control and

husband/boyfriend support were more consistentlyrelated to the outcomes of this study than was ex-pected for accompaniment to labor and delivery, only

the first two variables were included in the statisticalmodel as covariates.4

ARTICLES 91

At the 36th and 48th months of the children’s lives, they were

brought to the project offices for standardized testing by a school

psychologist. They were administered the Stanford-Binet FormL-M test of intelligence.

The children’s pediatric and hospital records were reviewed for

the period spanning 25 to 50 months of age; the interrater agree-ment for the abstraction of diagnostic codes entered in the medical

record (227 diagnoses for 166 visits for 21 children) was 90%.

Scales were constructed to characterize (1) the number of health

supervision visits; (2) the number of visits to the physician at

which separate illnesses were detected (ie, initial sick visits for an

illness plus well-child visits at which health problems were iden-

tified); (3) the number of injuries or ingestions noted in the phy-

sician’s record; (4) the number of child behavioral and parental

coping problems noted in the physician’s record; (5) the total

number of emergency department (ED) encounters; (6) the num-

ber of ED encounters for injuries and ingestions; (7) the number ofhospitalizations; and (8) the number of days hospitalized.

Child Protective Service records also were reviewed in New

York State as well as in the 14 other states to which families had

moved during the period between the child’s birth and his/her 4th

year of life. Child maltreatment data for the current report were

based on substantiated reports occurring between the children’s

second and fourth birthdays.

Combining Treatments 1 and 2 for Analysis

Treatments 1 and 2 were combined for purposes of analysis

after it was determined that there were no differences between

these two groups in their use of routine prenatal and well-child

care, the primary means by which transportation was hypoth-

esized to affect outcomes. The combination of treatments I and 2

hereafter is referred to as the Comparison group. Estimates of

treatment differences (and odds ratios) focused on the contrast of

treatment 4 versus the Comparison group for both the whole

sample and those groups defined as at-risk. We gave greater at-

tention to treatment 4 than treatment 3 because treatment 4 was

the only one to provide postnatal intervention, and the one with

the greatest chance of affecting outcomes.

Statistical Model and Methods

Dependent variables for which a normal distribution was as-

sumed were analyzed in the general linear model; the dichoto-

mous outcome (presence or absence of abuse or neglect) was

analyzed in the logistic-linear model (assuming a binomial distri-

bution); and low-incidence outcomes in the form of counts (eg,

number of emergency department visits) were analyzed in the

log-linear model (assuming a Poisson distribution). The model for

analysis of normally and binomially distributed variables was

based on a 3 x 2 x 2 x 2 factorial design with the following fixed

factors: treatments (three levels), maternal age at registration (14 to

18 years vs 19 to 34), maternal marital status at registration (mar-

ned versus unmarried), and social class (Hollingshead classes IV

and V versus I, II, and III). In the model for count data, age was

specified as a covariate rather than a classification effect to in-

crease the stability of model estimation. All interactions among the

classification factors were included in the models. Variables con-

structed to characterize maternal sense of personal mastery and

husband or boyfriend support were included as covariates be-

cause they were associated with the outcomes of interest and

because they showed treatment bias for selected subclass con-

trasts, as indicated below.We examined the extent to which covariates interacted with

categorical variables. Interactions between a covariate and I or

more categorical variables (nonhomogeneous regressions) mdi-

cate that certain tests of means depend on the covariate, in that a

different test exists for each covariate value. This investigation was

undertaken both to ensure correct interpretations of mean differ-

ences and to examine any substantive findings resulting from the

interactions between continuous and categorical effects!� Nonho-

mogeneous regressions with substantive meaning are illustrated

in Fig I and discussed under “Results.”

Estimates and tests were adjusted for all covariates, classifica-

tion factors, and interactions. The means presented correspond

directly to the tests: they are equally weighted averages of the

smallest subclass means, adjusted for the covariates. In the gen-

eralized case, the analysis was conducted and estimates were ob-

tamed in terms of the linearized form of the model-the logits (or

AVOIDANCE OF PUNISHMENT

(HIGHER NUMBERS = LOWER PUNISHMENT)

Figure. Fitted regressions of injuries and ingestions noted in

physician record on avoidance of punishment: comparison group

and nurse-visited (treatment 4).

log of the odds) in the logistic models, and the logs of the mci-

dence in the log-linear models. The tables show the estimates in

this form for the log-linear case; in the logistic case the estimates

are converted to odds for the individual groups and to odds ratios

for the treatment contrasts. Also shown in the tables is the trans-

formation of these estimates to proportions (for the logistic case)

and to incidence (labeled �) for the log-linear case. Confidence

intervals were derived from the variance of the estimates and were

placed on mean differences, the odds ratios, and on differences of

logs of the incidence. Analysis was by our own computer pro-

grams; iterative weighted least squares was used in the binomial

logistic-linear and Poisson log-linear models.

We show the results for treatment main effects as well as treat-

ment contrasts for the highest risk group defined by the classifi-

cation factors included in the model. For normally distributed

variables and the dichotomous variable, we show treatment effects

for low-income, unmarried teenagers. For the low-frequency

count variables, we show treatment effects for low-income, un-

married women (regardless of age). All statements of treatment

difference in the text are based on 95% confidence intervals; the

term “trends” refers to 90% confidence intervals.



Treatment Group Whole Sample Low-Income

Unmarried Teens

� N )� N

101.95

104.20

103.57

(148)

(78)

(88)

97.99

100.20

101.01

(30)

(16)

(20)

-1.61 -3.01

-6.08, 2.85 -11.65, 5.62

108.93

111.25

111.52

(148)

(78)

(88)

106.31

103.12

108.96

(23)

(14)

(21)

-2.59 -2.66

-6.77, 1.57 -10.73, 5.42

* Adjusted for marital status, social class, age, and all interactions among these factors, plus maternal sense of control and husband/

boyfriend support as covariates.

Attrition Home and Car Safety


During the first 4 years after delivery, the rates of

attrition varied from 15% to 21% (depending on as-

sessment period) and there were no differences acrosstreatments in the proportion of subjects with com-pleted assessments. The nurse-visited women who

discontinued the program, however, tended to havea greater sense of control over their lives (as measuredby a short form of Rotter’s locus-of-control scale24)than did those in the control group who discontinued.An examination of the reasons for these women’sdropping out of the program indicated that they hadeither moved or miscarried. Because a larger numberof women with greater sense of control discontinuedin the nurse-visited group than did those in the com-

parison group, the preintervention treatment differ-ence in sense of control for unmarried women wasreduced in the sample on which 46-month interviews

were conducted.

Child Abuse and Neglect

Although there were treatment differences in therates of child abuse and neglect for poor, unmarried,teenaged mothers while the program was in opera-tion,4 there were no enduring treatment differences inthe rates of new cases of child abuse and neglect dur-ing the 2 years after the program ended (Table 1).

Intellectual Functioning

Table 2 shows that there also were no overall treat-ment differences in the children’s Stanford Binet IQ

scores at 3 and 4 years of age.

Table 3 shows that the homes of nurse-visited fami-lies were observed to have fewer hazards for children

at the 34- and 46-month in-home assessments (P = .04and P = .003, respectively). On the other hand, therewere no program influences on the extent to which

mothers reported that poisonous substances werekept out of their children’s reach and that their chil-dren rode in cars with child safety restraints (data not

shown).

Health Care Encounters

As indicated in Table 4, between 25 and 50 monthsof life, in contrast to children in the comparisongroup, nurse-visited children had 40% fewer nota-

tions of injuries and ingestions and 45% fewer nota-

tions ofchild behavioral/parentalcoping problems inphysicians’ records (P = .03 and P = .006, respec-tively). During this period, nurse-visited childrenmade 35% fewer visits to the emergency department

(P = .0008). There were no program effects on numberof hospitalizations, but nurse-visited children spent58% more days hospitalized in the 25- to 50-monthperiod than did children in the comparison group(P = .02). This treatment difference was explained by

one outlying nurse-visited case (the most extremevalue in the sample) in which the child was hospi-

talized for 23 days for hemolytic uremic syndromeand transferred to a regional medical center for di-alysis. There was no evidence that the condition wasaffected by qualities of parental caregiving.

TABLE 1. Adjusted Means (and Odds) of New Cases o

Whole Sample and Low-Income, Unmarried Teens*f Abuse/Neglect from 25 to 48 Months of Life by Treatment Condition-For

Treatment Group Whole Sample Low-Income Unmarried Teens

Odds N Odds � N

Comparison .05

Treatment 3 .04

Treatment 4 .09

.05

.04

.08

(160)

(85)

(93)

.09 .08

.11 .10

.10 .09

(31)

(17)

(22)

Odds ratio (comparison/treatment 4) .56

95% confidence interval .00, 1.37

.90

.138, 6.30

* Adjusted for marital status, social class, age, and all interactions among these factors, plus maternal sense of control and husband/

boyfriend support as covariates.

TABLE 2. Adjusted Mean IQ Scores at 3 and 4 Years of Age by Treatment Condition-For Whole Sample and Poor, Unmarried Teens*

Stanford Binet, 36 mo

Comparison

Treatment 3

Treatment 4

Difference (comparison - treatment 4)

95% confidence interval

Stanford Binet, 48 mo

Comparison

Treatment 3

Treatment 4





TABLE 3. Adjusted Means (and Log Incidence) of Home Hazards at 34 and 46 Months of Life by Treatment Conditions-For Whole

Sample and Poor Unmarried Women*

Whole Sample Low-Income Unmarried Women

Log Incidence X N Log Incidence X N



Hazardous exposures observed in home, 46 mo

Comparison

Treatment 3

Treatment 4



.71t .94

.02, 1 .41 -.05, 1.92

-1.04 .38 (129) -1.06 .35 (57)

-1.76 .23 (73) -1 .02 .36 (28)

-1.75 .22 (80) -2.00 .14 (30)

-.83 .46 (129) -.95 .38 (57)

-1.23 .31 (73) -1.26 .28 (28)

-1.94 .21 (80) -2.35 .10 (30)

I.1I� 1.40t

.39,1.83 .18, 2.62

* Adjusted for marital status, social class, and all interactions among these factors, plus maternal sense of control, husband/boyfriend

ARTICLES 93

Dependent Variable and

Treatment Group

Hazardous exposures observed in home, 34 mo

Comparison

Treatment 3

Treatment 4

support, and age as covariates.

tP < .05.

:t:P < .01.

Warmth, Control, and Involvement

There were no treatment differences in the inter-viewers’ ratings of mothers’ warmth or control at ei-

ther the 34th or 46th month observation, but at the34th month nurse-visited mothers were rated as moreinvolved with their children than were mothers in thecomparison group (P = .004) (data not shown).

Home Inventory

Although there were no overall treatment differ-

ences on the Home Inventory total score at either 34or 46 months, there was a strong trend for the homesof nurse-visited poor, unmarried teens to be givenhigher scores at the 34th month assessment in contrast

to poor, unmarried teens in the comparison group (P= .06) (Table 5). This difference in total score was

explained by the nurse-visited poor, unmarried teens’greater stimulation of their children’s language skills(P = .005 and P = .01, for the 34th and 46th month

assessments, respectively), and greater provision oftoys, games, and reading materials at the 34th month(P = .03). At the 46th month assessment, nurse-visitedwomen overall were observed to punish their chil-dren more frequently than were women in the com-parison group (P = .009). This effect was particularly

strong for low-income unmarried women who wereolder (P = .007)-those nurse-visited women who, in

earlier reports, were shown to have joined the workforce more rapidly after delivery and to a greater ex-tent during the first 4 years postpartum than their

counterparts in the comparison group.9

Meaning of Increased Restriction and Punishment

Among Nurse-Visited Parents

The higher level of punishment found amongnurse-visited families at 46 months may have been anunintended negative side effect of the program or itmay reflect higher standards and stricter enforcement

of parental rules, leading to superior child function-ing. To address this issue, we regressed selected de-pendent variables on the avoidance-of-punishment scaleseparately for nurse-visited and comparison families.Among comparison group families, an increase in

punishment was associated with an increase in ad-verse outcome, but this was not always the case

among nurse-visited families. This pattern is illus-trated in Fig I . Here we see the estimated regressionsof injuries and ingestions in the physician record onavoidance of punishment, specified separately for

nurse-visited and comparison group families. The re-

gression coefficients were significantly different (P =

.049), indicating a treatment difference in the func-tional meaning of punishment. In the comparisongroup, the regression of injuries and ingestions on

avoidance of punishment was negative (�3 = -.2340,

P = .21), whereas among nurse-visited families theslope of the relationship was positive (f3 = .5848, P =

.11); this suggests that higher levels of punishment

were associated with fewer injuries and ingestionsamong nurse-visited families, but with more injuries

and ingestions among comparison families. A similarpattern was present for the regression of ED encoun-ters for injuries and ingestions on avoidance of pun-ishment, where the treatment difference in regression

coefficients was marginally significant (P = .07).These findings indicate that the treatment differences

for injuries and ingestions (both in the physician’s re-cord and in ED encounters) were concentrated amongmothers who displayed higher levels of punishment.

Summary of Findings

DISCUSSION

During the 2 years after the program ended, therewere no enduring program effects on the rates of childabuse and neglect or on children’s intellectual func-

tioning. There were, however, lasting program effectson the safety of the households; children’s use of theemergency department; use of physicians’ offices forinjuries and ingestions and child behavioral and pa-rental coping problems; and the qualities of care thatpoor, unmarried teenagers provided to their children.Moreover, nurse-visited mothers overall were ob-served to be more involved with and to punish theirchildren to a greater degree than were mothers in thecomparison group.



. . . 1.56

. . . 1.27

. . . 1.26

.30

-.04,64

. . . 6.72

. . . 5.18

. . . 6.24

(137)

(72)

(84)

(137)

(72)(84)

-2.67,2.64

-.34, 1.01

No. scheduled health supervision visits with problems

or initial sick visits

Comparison

Treatment 3

Treatment 4



No. injuries/ingestions in physician record

Comparison

Treatment 3

Treatment 4



No. behavioral/coping problems in physician record

Comparison

Treatment 3

Treatment 4



No. emergency department visits

Comparison

Treatment 3

Treatment 4



No. emergency department visits for injuries/ingestions

Comparison

Treatment 3

Treatment 4



No. hospital admissions

Comparison

Treatment 3

Treatment 4



No. days hospitalized

Comparison

Treatment 3

Treatment 4



-.14

-.68, .39

.38+

.01, .75

-.12

-.70, .45

-1.00, 1.20

.31 (137) -2.02

.43 (72) -1.16

.49 (84) -.44

-1.58�

-2.42, -.75

* Adjusted for marital status, social class, and all interactions among these factors, plus maternal sense of control, husband/boyfriend

support, and age as covariates.

f P � .05.

:�:P � .01.


TABLE 4. Adjusted Means (and Log Incidence) of Health Care Encounters from 25 to 50 Months of Life by Treatment Condition-For

Whole Sample and Low-Income, Unmarried Women*

Dependent Variable and Whole Sample Low-Income Unmarried Women

TreatmentGroup � � - � � �Log Incidence X N Log Incidence X N

No. scheduled health supervision visits

Comparison

Treatment 3

Treatment 4



-.59

-.62

1.09

.50t

-.04, .96

-.40

-.87-1.27

.87�

-.25, 1.47

.42

.21

-.10

.52j

.21, .81

-.51

-.82

-.88

.37

-.08,81

-5.40

-2.27

-5.30

.10

-.17,17

-1.46

-1.22

-.80

-.66t

-1.21, -.13

.48

-1.36, 2.33

.57 (137) -.61

.56 (72) -.56

.34 (84) -.94

.33

.71 (137) -.60

.43 (72) -.55

.39 (84) -.46

1.53 (137) .54

1.24 (72) .17

1.00 (84) .16

.61 (137) -.64

.46 (72) -.79

.47 (84) -.52

.11 (137) -1.71

.11 (72) -1.53

.14 (84) -1.81

.10

. . . 1.33 (59)

. . . 1.32 (28)

. . . 1.05 (32)

.28

-.20, .76

. . . 5.72 (59)

. . . 4.68 (28)

. . . 5.74 (32)

-.02

.55 (59)

.57 (28)

.39 (32)

.55 (59)

.58 (28)

.63 (32)

1.72 (59)

1.18 (28)

1.18 (32)

.53 (59)

.45 (28)

.60 (32)

.18 (59)

.22 (28)

.16 (32)

.13 (59)

.31 (28)

.65 (32)

How Does This Type of Home Visitation Produce Its

Effects?

The interpretation of these effects, in our judgment,

must be made in the context of the program influenceon the life course development of at-risk women. In

earlier reports we showed that low-income, unmar-

ned women visited by nurses in this trial were morelikely to participate in the work force and to delay

subsequent pregnancies during the first 4 years after

delivery than were their counterparts in the compari-son group)’ Research on cultural and occupationalinfluences on childrearing indicates that the social-

ization agendas parents establish for their childrenand the type of care that they provide is influenced by

their interpretation of what society will demand oftheir children in their adult economic and social



Dependent Variable and

Treatment Group

TABLE 5. Adjusted Means of Home Inventory Scores at 34 and 46 Months of Life by Treatment Condition-For Whole Sample and

Low-Income, Unmarried Teens*

Whole Sample

x N

Low-Income

Unmarried Teens

39.03

38.45

39.08

-.05

-1.92, 1.84

N

Home inventory (total score), 34 mo

Comparison

Treatment 3

Treatment 4



Home inventory (total score), 46 mo

Comparison

Treatment 3

Treatment 4



Stimulation of language skills, 34 mo

Comparison

Treatment 3

Treatment 4


(78)(89)

34.05

38.96

(15)

(19)

-3.54

-7.24, .156

39.67

40.18

39.66

(149)

(78)

(89)

36.67

36.16

38.85

(30)

(15)

(19)

.01 -2.18

-1.66, 1.67 -5.46, 1.11

5.57

5.41

5.72

(138)

(75)

(87)

5.12

4.93

6.14

(29)

(15)

(18)

-.15 -1.02+

95% confidence interval -.51, .21 -1 .73, -.30

Stimulation of language skills, 46 mo

Comparison 6.28 6.03

Treatment 3 6.32 6.21


Difference (comparison - treatment 4) -.11 -.68+

95% confidence interval -.38, .16 -.012, -.14

Provision toys, games, reading materials, 34 mo

Comparison 8.37 7.25



Difference (comparison - treatment 4) .00 -1 .26�

95% confidence interval -.56, .56 -2.36, -.16

(138)

(75)(87)

(29)

(15)

(18)

(138)

(75)(86)

(29)

(15)

(18)

Provision toys, games, reading materials, 46 mo

Comparison

Treatment 3

Treatment 4



Avoidance of Punishment, 34 mo

Comparison

Treatment 3

Treatment 4



6.92

7.32

6.84

(138)

(75)(86)

.08

-.51,69

6.12

5.90

6.95

(29)

(15)

(18)

-.83

-2.00, .35

2.87

2.78

2.93

(130)

(74)

(81)

-.06

2.65

2.40

2.56

-.38, .26

(27)(15)

(18)

.09

Avoidance of punishment, 46 mo

Comparison

Treatment 3

Treatment 4

Difference (comparison - treatment 4) .37+ .30

95% confidence interval .09, .65 -.23, .82

3.21

2.85

2.84

-.50, .69

(130)

(74)

(81)

3.01

2.57

2.72

(27)(15)

(18)

* Adjusted for marital status, social class, age, and all interactions among these factors, plus maternal sense of control and husband /boyfriend support as covariates.

tP < .01.

:�:P < .05.

ARTICLES 95

roles.23’26 In view of the nurse-visited women’s greaterparticipation in the work force, it is reasonable that

they would grow to expect at least comparable levelsof eventual participation in the work force by their

children. The higher rates of involvement and pun-ishment and improved safety of their households, webelieve, are reflections of their greater belief that their

children must be disciplined and protected for them

to succeed in school, work, and mainstream society.The relative lack of involvement and reduced use of

punishment on the part of mothers in the comparison

group, we hypothesize, reflects lower expectations for

their children’s participation in mainstream society,and reduced efforts to promote discipline, confor-mity, and safety. This interpretation is supported bythe different relationship observed between punish-




ment and physician visits for injuries and ingestions

depending on whether mothers were visited by

nurses or in the comparison group.Although we cannot rule out the possibility that the

higher rates of punishment on the part of nurse-visited women are the result of early mother-childseparation, weakened attachment, and increased be-havioral problems due to increased participation in

the work force,27 recent evidence suggests that higher

levels of punishment and restriction on the part of

parents in low-income communities (and especially

those with high rates of crime) are associated with

greater competence on the part of children when they

reach adolescence.28In our view, the treatment differences observed in

the current study in home safety, caregiving, health

care encounters, maternal employment, and subse-

quent pregnancy after the program ended create an

increasingly coherent picture that the lives of nurse-visited and comparison families were moving in sub-

stantially different directions by the time the childrenwere 4 years old. This divergence in life course, in our

judgment, is a result of both the content and process

of the program.The content of the program focused on the promo-

tion of mothers’ self-efficacy with respect to theirhealth-related behaviors, completing their educa-

tions, participating in the work force, planning futurepregnancies, as well as the care of their children (in-

cluding safety of the household, physical care of thechild, and promotion of the child’s socioemotional

and cognitive development). The integration of these

content areas in the same program, we believe, maxi-mized its capacity to change behavior.

A critical feature of program process was the de-

velopment of a close therapeutic alliance between the

nurse and the mother. That relationship, we hypoth-

esize, enabled them to participate in and understand

one another’s worlds. It helped the mothers envisionlife options for themselves that otherwise would nothave been possible. It helped the nurses understand

those forces in the mothers’ lives that both interferedwith and promoted their chances for life success. The

connection of their separate social systems throughtheir relationship strengthened the power of the pro-

gram to produce significant shifts in the life coursedevelopment and caregiving of the nurse-visited

women.

It will be important to test these hypotheses about

personal, parenting, and program processes in future

preventive intervention studies.

How Did the Program Reduce Health Care Utilization?

The program effects on emergency department en-counters and injuries and ingestions noted in the phy-

sician record during the follow-up period are consis-

tent with effects observed for this program on EDencounters for injuries and ingestions during the sec-ond year of the child’s life (when the children first

became at risk for injuries and ingestions because of

their increased mobility).4 These reductions in healthcare encounters raise questions about whether they

are the result of improvements in the health of thenurse-visited children or simply altered patterns of

utilization.If these reductions reflect only altered patterns of

utilization, we reasoned that they may be due to themothers’ becoming ineligible for Medicaid as a result

of their joining the work force to a greater extent thancomparison families. Medicaid ineligibility wouldcreate a disincentive for health care utilization if par-ents did not have a corresponding increase in privatehealth insurance. To address this issue, we assessed

families’ reported use of welfare at the child’s 46thmonth of life and examined the treatment differencesin health care utilization after adding use of welfare

as a covariate to the core statistical model outlinedabove. We found that the program effects remainedessentially unchanged, even though nurse-visitedwomen, as a trend, reported lower use of welfare atthe 46th month of the children’s lives than did familiesin the comparison group. The absence of a reduction

in treatment effect for the identified health care en-counters after control for use of welfare indicated thatthe program effect was not simply due to reduced

Medicaid eligibility (the most likely reason for re-duced utilization other than improved health). More-over, the pattern of treatment differences in the typesof health care encounters (eg, notations of injuries andingestions) supports our interpretation that the pro-gram effect is due to improved child guidance andsafety of the home environment.

Effects of the Program on Maltreatment

Although it is disappointing to find no enduringeffects of the program on the rates of maltreatmentafter the program ended, it is important to note thatnurse-visited children from high-risk families were

maltreated less frequently while the program was inoperation,4 and those nurse-visited children whowere maltreated were substantially different than thechildren in the comparison group who were mal-treated. We have reported elsewhere for that nurse-visited children and families indicated for maltreat-ment during the first 4 years of the child’s life werefunctioning better during the follow-up period thanwere their comparison group counterparts, as mdi-

cated by fewer injuries and ingestions noted in thephysician record and higher Home Inventory scores

at 46 months.29We have no direct evidence to explain why the

nurse-visited maltreating families would be function-ing better than their comparison group counterparts,but we hypothesize that it is due to the different sys-tems of surveillance in place for the two groups of

families. Although nurse-visited women probablylearned more optimal methods of caregiving from thenurses, the differences in health and well-being be-tween the children in the nurse visited and compari-

son groups who had been maltreated were too largeto be attributable solely to the nurses’ promotion ofsuperior caregiving. The greater surveillance ofnurse-visited families (by both the nurses and otherhealth and human service providers with whom the

families were linked) probably led those at-risk formaltreatment to be referred to Child Protective Ser-



ARTICLES 97

vices at earlier stages in the development of caregiv-

ing dysfunction than at-risk families in the compari-son group, who were relatively isolated and who hadto reach more serious stages of dysfunction before

they were reported.Considered from the standpoint of program de-

sign, the absence of an enduring effect on the rates of

child maltreatment suggests that it may be necessaryto continue home visitation beyond the 24th-month-

of-life termination point currently employed whenserving families at greatest risk. We should empha-size, nevertheless, that the reduction in seriousness of

the nurse-visited maltreated cases found in the cur-rent study are indications of positive program effects.

Cognitive and Language Development

Even though we observed continued influence of

the program on the extent to which poor, unmarriedteenagers stimulated their children’s language skills,and provided educationally stimulating toys, games,and reading materials to their children, there were no

corresponding enduring effects of the postnatal pro-gram on their children’s intellectual functioning. (AtI and 2 years of age, the children of nurse-visited poor,

unmarried teens had developmental quotients thatwere 1 1 and 9 points higher than their counterparts inthe comparison group.4) The absence of an enduring

program effect on children’s intelligence suggests thatif the program is going to have any influence on the

children’s school achievement and adaptation it willbe through parents’ promotion of high standards,

hard work, and discipline rather than through thepromotion of specific cognitive skills.

In finding no overall lasting effect of the postnatalprogram on the children’s intellectual functioning,the current program is similar to other early inter-vention programs.�#{176} We should note, however, thatthe prenatal program did produce an enduring effect

on the intellectual functioning of preschoolers born towomen who smoked substantially when they regis-

tered in the study during pregnancy, due in part to areduction in cigarette smoking and improvement indiet during pregnancy.’2”3 The emphasis of the pro-

gram on pregnancy and health thus distinguishes the

current program from other preventive interventionsand provides another mechanism through which itproduces long-lasting effects for at-risk groups.

Limitations of the Findings

Finally, these findings must be viewed with cau-

tion. Before the provision of services, the nurse-

visited, unmarried women exceeded their compari-son group counterparts in sense of personal control,and the nurse-visited poor, unmarried teenagers ex-ceeded their counterparts in boyfriend support. Al-though we adjusted statistically for these preinterven-

tion differences, it is possible that there were otherassociated conditions that biased the sample in un-

known ways. It should be emphasized, nevertheless,that these preintervention differences were attenu-

ated because nurse-visited women with a greater

sense of control discontinued the study more fre-quently than did their comparison group counter-parts. Moreover, no other preintervention differences

were detected after a careful examination of the

sample for a wide range of conditions that might biasrelevant treatment contrasts.

Another reason for caution in interpretation is that

findings in favor of the nurse-visited, poor, unmar-ned teenagers for the Home Inventory have a greater

chance of being sampling artifacts than do findingspresent for the sample as a whole, because random-

ization was not carried out within all of the subgroupson which the sample was stratified for analysis. Weshould emphasize, however, that the randomizationwas stratified on the basis of mothers’ marital status,

race, and geographic region in which they lived.Moreover, the contrast for the poor, unmarried teens

emerged from a series of planned comparisons in-corporated in a set of statistical models that includedfactors (risk characteristics) identified at the stage of

research design and used for sample recruitment. Inaddition, we have shown in reviews of other random-ized trials of prenatal and infancy home visitation

programs that the positive findings of such programsare concentrated on higher risk families, and particu-larly those in which the parents are low-income, un-

married teens.8’3’There are several features of the present study that

limit its generalizability to other programs and com-munities. First, the program was conducted under fa-vorable circumstances. The nurses were hired andtrained exclusively for this experimental program,and each nurse carried a manageable caseload. Sec-ond, the community in which the research was con-ducted is not representative of inner cities or ex-tremely isolated rural communities. Third, althoughthe women and children enrolled in this study do rep-

resent a substantial portion of the women and chil-dren in the United States, there are many to whomthese results cannot be applied (eg, African Amen-cans, those who register for prenatal care after 30weeks of gestation). Consequently, the present study

should be replicated in other settings, with other

populations, and using different administrative an-rangements for the program before its findings are

used as a basis for major policy or program initiatives.We are conducting replications of the current trial inMemphis, Tennessee, and Denver Colorado to ad-dress this issue.3233

In spite of these limitations, it is increasingly clearthat home visitation by nurses during pregnancy andthe first 2 years of the child’s life can be an effectivemeans of promoting the health and well-being of low-income, at-risk mothers and children and reducing

future government expenditures for this population.’2If we are to translate these findings into effective poli-

cies and programs, we must continue to search for

those individual, institutional, and community fac-tors that contribute to and interfere with program

success.

ACKNOWLEDGMENTS

This research was supported by grants from the Bureau of

Community Health Services (MCJ-360579 and MCJ-360403), theNational Center for Nursing Research (ROl NR001691-O1AI), the

Robert WoodJohnson Foundation (grants 5263 and 6729), the W.T.

Grant Foundation (grants 800723-80 and 840723-80), the Ford

Foundation (grants 840-0545 and 875-0559), a Biomedical Re-




search Support Grant (National Institutes of Health) (PHS

S7RR05403-25), the Commonwealth Fund (grant 10443), and a

William 1. Grant Faculty Scholars Award to the first author (grant

861-080-86).

We thank Robert Haggerty, Zorika Henderson, Robert Hoekel-

man, Elizabeth McAnarney, and Joanme Pinhas for their corn-

ments on the manuscript; Moira Birmingham and Jim Lombardi

for supervising the data gathering and processing; Kathy Burwell,

Karen Hughes, Janice Sheppard, and Kim Sidora for their help

with preparation of the manuscript and processing the data; John

Shannon for his administrative support of the program; Robert

Chamberlin and Robert Tatelbaum for serving as coinvestigators

on the original trial; and Elizabeth Chilson, Diane Farr, Geor-

gianna McGrady, Jacqueline Roberts, and Lyn Scazafabo for their

work with the families enrolled in the program.

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of Parental Caregiving and Child Health at 25 to 50 Months of Life?Does Prenatal and Infancy Nurse Home Visitation Have Enduring Effects on Qualities

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